Cultural Identity and Trauma. Construction of meaning among Afghan and Iraqi refugees under treatment in Dutch mental health care

Most refugees from post-conflict areas have experienced a multitude of shocking
events. These events may lead to psychiatric disorders. According to Gerritsen
et al (2006) 68 % of Afghan, Iranian and Somalian refugees in The Netherlands
suffer from anxiety or depression disorders and 28 % from posttraumatic stress
disorder (PTSD). Laban (2010) has found that the length of the asylum procedure
increases the number of psychiatric disorders among Iraqi refugees in The
Netherlands, from 42 % in the group that was in The Netherlands for six months
or less up to 66 % in the group that was in The Netherland for two years and
more. Psychiatric treatment of these disorders has resulted in discussions
about the cultural diversity of perceptions of traumas and their consequences
in the form of psychiatric disorders. In the Netherlands some psychiatrists
make use of the scarcely available anthropological knowledge to make
psychiatric diagnosis and treatment cultural sensitive. They primarily used the
anthropologically informed guidelines and concepts that are available in the
fourth edition of the Diagnostical and Statistical Manual for Mental Disorders
(DSM-IV): the Cultural Formulation of Diagnosis, idioms of distress and culture
bound syndromes. In-depth knowledge of the impact of culture on individual
perceptions and experiences of traumas and their related psychopathology among
refugees is hardly available. Small-scale comparative research proved that this
knowledge was highly relevant for accurate culture sensitive diagnosis and
treatment among this particular group of patients in inpatient care (Groen &
Laban 2011). Research among larger samples of refugees is needed in order to
corroborate these findings and develop specific guidelines for psychiatrists to
enhance culture sensitive diagnosis and care.

The main purpose of this PhD research is to obtain more insight in the
interplay between psychopathology and cultural identity among refugees from
Afghanistan and Iraq and to contribute to more effective treatment plans.
Information about the cultural identity is relevant in treatment because this
identity may be affected by shocking events that may lead to psychopathology.
Another important cause of identity change is migration and the related post
migration living problems. It is relevant to know how strong the associations
are between these problems and mental wellbeing. Much of this information is
not known when patients with psychopathology are being referred for psychiatric
treatment. Clinical experience has shown that psychiatrists are in need for
this information. Research among Afghan and Iraqi refugees must show whether
patterns can be distinguished in which psychopathology has an impact on
cultural identity and vice versa.

Three main research questions can be distinguished, each followed by several
sub questions:

1. What is the relation between psychopathology and cultural identity?
Sub questions:
- Are there differences in the relation of psychopathology with various aspects
of cultural identity between Afghans and Iraqis?
- What is the relation between traumatic symptoms that are reported in HTQ and
HSCL and various aspects of cultural identity?

2. What is the relation between shocking events and post-migration living
problems on the one hand and cultural identity on the other?
Sub questions:
- How do shocking events relate to the cultural identity of Afghan and Iraqi
refugees?
- How do shocking events relate to their acculturation process?
- Does psychopathology seem to be related to the acculturation process of
Afghan or Iraqi refugees?
- To what extent are problems that are related to cultural identity also
related to shocking events and/or the acculturation process of Afghan and Iraqi
refugees in treatment?
- What aspects of cultural identity of Afghan and Iraqi refugees are related
with shocking events?

3. Does information on the interplay between shocking events, post migration
living problems, psychopathology and cultural identity lead to more adequate
treatment plans?
Sub questions:
- Does attention to cultural identity of Afghan and Iraqi refugees with
psychopathology lead tot more adequate treatment plans?
- How does the use of information about cultural identity and psychopathology
in caretaking lead to more adequate treatment plans?

This mixed-method study will consist of a qualitative and a quantitative part.
In the quantitative part the associations between shocking events,
psychopathology, post-migration living problems on the one hand, and cultural
identity on the other hand will be measured. In the qualitative part the
complex interplay between these shocking events, psychopathology,
post-migration living problems and cultural identity will be studied.

Concerning the qualitative part of the research, cultural identity will be
described using the cultural interview and participant observation through home
visits.

For those in contact with the Evenaar the cultural interview and the first two
questionnaires (HTQ and the HSCL-25) are already part of common treatment. This
interview en these questionaires will take one hour maximum. For reseach
purposes the sociodemografic form and three extra questionaires (PMLP-CL,
CRM-BS, CES) will have to be answered wich will take approximately an extra
hour maximum. For those who are not in treatment the whole assesment will take
two hours. For those twenty people that will be visited at home participation
in the study will take an extra two hours.

Benefits from the study (better understanding of trauma and coping and more
effective treatment) can have an influence both on those respondents in care as
well as those not in care. The choice of the research groups is directly
influenced by the main research questions as there is a large group of Iraqi
and Afghan refugees represented in Dutch mental health care.