Military Psychiatry and Refugees Chapter 15 MILITARY PSYCHIATRY AND REFUGEES FRANKLIN D. JONES, M.D., F.A.P.A.,* PINCHAS HARRIS, M.D.,† MANUEL FEBO, M.D.,‡ AND PEDRO J. CRUZ, M.D.§ INTRODUCTION TYPES OF DISPLACEMENT Refugees Migrants Voluntary Exiles SOCIAL IMPLICATIONS PSYCHOLOGICAL IMPLICATIONS Initial Phase Phase of Preentry Phase of Entry Period of Psychological Arrival Period of Resettlement MILITARY ASSISTANCE: THE CUBAN MARIEL BOAT PEOPLE Psychological Phases Patient Data Profile Discussion SUMMARY AND CONCLUSION *Colonel (ret), Medical Corps, U.S. Army; Clinical Professor, Uniformed Services University of the Health Sciences; Past President and Secretary and Current Honorary President of the Military Section, World Psychiatric Association †Director of Rehabilitation Services, Herzliya Medical Center—Haifa, Israel; formerly Medical Officer, Israeli Defence Forces ‡Colonel (ret), Medical Corps, U.S. Army; formerly Psychiatry Consultant to The Surgeon General, U.S. Army; formerly Chief, Inpatient Psychiatry, Walter Reed Army Medical Center, Washington, D.C. §Chief, Department of Psychiatry, Caguas Regional Hospital, Caguas, Puerto Rico 251 Military Psychiatry: Preparing in Peace for War INTRODUCTION The 20th century may be described as the century The military is called to assist when the influx of of the uprooted or homeless man.1 Since the begin- refugees is so great that civilian organizations have ning of the century and especially since World War difficulties in coping with all of the initial prob- II, there have been millions of displaced persons in lems.10,11 Such a state has developed numerous times various parts of the world at the same time. As of in the United States. In 1975, the large number of April 1991, there were nearly 15 million refugees Vietnam refugees who arrived in California were worldwide, mostly women and children. More than assisted by the navy.12 In 1979 and 1980, the influx of 2 million are “boat people” escaped from repressive Cubans who arrived in Florida required the army to regimes or civil war in Southeast Asia, and 1.6 assist in various aspects.13 In 1992 and 1993, an million of these were resettled in 30 countries since influx of Haitian refugees was threatened and only 1975.2 The 1991 to 1992 dissolution of Yugoslavia aborted by a navy blockade of Haiti.14 Naval action and ethnic fighting have added several more mil- was also required to stem an influx of refugees from lions to these figures.3,4 The recent tribal fighting in China.15 Most of these recent refugees are seeking to Rwanda has added over 200,000 refugees fleeing to better their economic situation, a chronic cause of neighboring countries.5 illegal aliens from Latin America and developing Much has been written in the scientific litera- nations.16 ture1 on the various aspects of the refugee prob- Another such situation requiring military assis- lem, but relatively little has appeared in the psy- tance occurred in the summer of 1992 when Hurri- chiatric literature until recently. Psychiatrists cane Andrew devastated areas of southern Florida have usually been interested in psychiatric mor- and Louisiana, the costliest natural disaster in U.S. bidity of the resettled refugees, while only a few history up to that time. The military was required to papers have been devoted to psychiatric phe- maintain order and set up refugee camps.17 Finally, nomena encountered in the initial stages of refu- large-scale flooding in the midwest United States gee resettlement.6 resulted in massive numbers of refugees in 1993.18 An area of particular interest for psychiatrists is Under current policy and law, military assis- treating the post-traumatic stress disorders that tance is only temporary and only in the initial stages refugees may suffer as a result of exposure to mass until civilian organizations can take over completely. violence and torture. A few studies7,8,9 have indi- We shall describe, therefore, psychiatric and psy- cated that psychiatric interventions may be helpful chological phenomena that can be seen in the early in reducing depression and anxiety symptoms in stages of resettlement, after first defining different these refugee populations. categories of displaced persons. TYPES OF DISPLACEMENT Refugees status may also be transient as occurred with Hur- ricane Andrew and the 1993 Midwest flooding in The most common type of displacement of mod- the United States. In this chapter, we will use the ern times is the refugee. In this situation, the indi- term refugee to refer to someone who has left his vidual is forced to leave his previous home and country of origin, unless otherwise stated. does not expect to be able to return home in the future. Refugee situations occur as a result of war Migrants (for example, Afghanistan, Iran, Iraq, Yugoslavia, and Central America) or as a result of political A migrant is someone who voluntarily decides to changes that force specific communities and racial, leave his homeland, looking for a new life in a new ethnic, religious, or political groups to leave their country. The individual in this situation has the homes and countries (for example, Vietnam, Cam- possibility of returning to his previous country so bodia, Laos, Haiti, Bulgaria, and Rwanda). It is that there need not be a total discontinuation with refugees that we discuss in detail later. Refugee the past. Even though this is a self-initiated process 252 Military Psychiatry and Refugees controlled by international agreements, the receiv- est of all types of displacement and rarely causes ing country can be faced by large numbers of immi- strain on immigration authorities of the accepting grants. This situation rarely needs assistance from countries although there are some instances of mass military sources because the influx is regulated and voluntary departure of individuals from their home- the immigrant is required to have a sponsor. land. The influx of Cubans to the United States in 1979 and 198019 and the Jewish flight from the former Voluntary Exiles Soviet Union20 can be seen as examples. In addition, the 1992 flight of ethnic groups from Yugoslavia Voluntary exiles are people who, by voluntarily sparked riots in Germany where they were viewed leaving their homeland, know that they cannot re- as competitors for scarce jobs and welfare re- turn, that is, unless there is a radical political change sources.21 Some phenomena in the various stages of in their country of origin. This type of displacement resettlement are common to all types, the main is encountered when people leave totalitarian re- sufferer being the refugee who had no control over gimes of their own accord. This group is the small- his flight. SOCIAL IMPLICATIONS Three social conditions are common to almost refugee becomes homeless. He loses his economic all refugees: statelessness, homelessness, and stability, gives up previous personal and cultural powerlessness. ties, and becomes a stranger in a new society. By being forced to leave his country, either by A refugee is generally a person who has no home, reason of war or politics, a refugee becomes state- who has no power or control over his flight or fate, less. He loses his status of citizenship and thus loses and who is in the hands of others for survival and the rights and the protection each citizen receives later resettlement. When the individual overcomes from his country. Being evicted from his home, a these obstacles, he ceases to be a refugee. PSYCHOLOGICAL IMPLICATIONS The clinical picture encountered among refugees The initial phase terminates when the individual is extremely varied both in individual responses has successfully managed to arrive in a new sur- and in changes within the individual over time. To rounding that does not impose any specific danger understand these phenomena, we suggest the fol- to him. The suffering in this phase can definitely lowing phases of responses be considered in what impair the resettlement of the refugee. shall be called the refugee syndrome. Our sugges- The psychological phenomenon seen in this stage tion is based in part on what Tyhurst22 calls the can be defined as “survival.” The individual wants social displacement syndrome. The phases are to live, and he does everything in his power, con- initial phase, phase of preentry, phase of entry, sciously and unconsciously, to remain alive. period of psychological arrival, and period of resettlement. Phase of Preentry Initial Phase In the phase of preentry, the refugee has arrived at a safe place, but as yet he does not know where he The initial phase is the period in which the indi- is going to settle or which country is going to allow vidual becomes a refugee. He has been evicted from him to enter. This phase is mainly seen when there his home and surroundings. The refugee in this is a mass influx of refugees to a country that cannot stage usually has terrifying or threatening experi- or that is unwilling to resettle all of the refugees. ences caused by war, disaster situations, or captiv- The period can last for years, with the refugee being ity and jailing because of political reasons. This in an internment camp without being able to begin period is characterized by various degrees of physi- the process of resettlement. cal discomfort such as hunger, physical illness or This period can also be a period of selection, injury, torture, and so forth. when one country agrees to accept a certain number 253 Military Psychiatry: Preparing in Peace for War of refugees for resettlement. The obvious choice for that we see the influence of the group and leader- selection are the young, the healthy, the skilled, and ship diminishing.10 the more educated, while the others await some other solution. Period of Psychological Arrival Psychological phenomena encountered in this period are comparable with those experienced dur- The period of psychological arrival is the time ing phases of disaster, namely the recoil period.10 when the refugee awakens from his “daze” and Responses consist of three main behavior patterns: begins to realize the difficulties of building a new (1) effectiveness, (2) dependency, and (3) life.