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msJAMA
March 7, 2001

From War Zone to Contact Zone: Culture and Refugee Mental Health Services

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JAMA. 2001;285(9):1214. doi:10.1001/jama.285.9.1214-JMS0307-4-1

It is no longer appropriate to conceptualize a world in which the movement of refugees is one way and permanent, or where health care professionals can consider themselves naive outsiders. Contemporary habits of travel and communication have placed much of the world's population in "complex connectedness."1 Paradigms of cultural competence based only on recognizing cultural difference are not sufficient to take into account the subtleties and importance of the cross-cultural interactions between refugees and mental health services. Instead, paradigms from the "new ethnography"1 that reflect how cultures engage and influence one another must be incorporated into the delivery of mental health services.

Existing frameworks for understanding refugee mental health services have emphasized the idea of the "war zone." This framework prioritizes the result of exposure to war traumas and emphasizes concepts such as posttraumatic stress disorder, damaged self, and psychotherapy, while relegating issues concerning culture to the background. These are culture-based assumptions that influence the choices that mental health professionals make about refugee services. Traditionally, mental health services tend to focus on treatments for individuals who are willing to present themselves as "patients." Relatively few refugees, however, are willing to be patients, although many suffer.2 A leading scholar of the new ethnography, James Clifford proposes the "contact zone"3 as a place of exchange, interpenetration, and negotiation between 2 or more worlds. Health care services, from a contact zone perspective, are not universal receptors that any incoming refugee group can plug into, nor are they a plug that can fit in the socket of every post-war nation. Rather, each situation is a complicated interaction between refugees and professionals, shaped not only by the particulars of a given location, but also by persons, professionals, ideas, policies, or monies from far away.

I used a contact perspective to investigate historical memory in Bosnia-Herzegovina.4 I would like to provide several examples of ways in which new conceptualizations of culture can affect services for refugees. First, talking about trauma through interpreters does not necessarily make for culturally relevant care, nor does placing a mental health clinic in a community necessarily make the clinic inviting to that community. The "contact zone" perspective insists that providers take a closer look at how professional ideology, service organizations, and refugees' attitudes may result in a pattern of underutilization of refugee mental health services, and how this might be changed.

Second, the contact zone perspective shows that a crucial missing element in refugee services is a focus on the family and its strengths. The "CAFES" (Coffee and Family Education and Support) intervention was developed through a commitment to collaboration between mental health professionals and Bosnian families in Chicago. CAFES is a multi-family support and education group run by lay Bosnian refugees who are trained by an interdisciplinary professional team, based on the principles that the family is of central importance and that families are strong and good. This approach, itself a cross-cultural product, fits better with the needs and strengths of Bosnian refugee families.

Third, the contact perspective can be useful in managing cultural issues concerning the relationship between international and local professionals. Too often, international professionals' investment in promoting ideas from outside exceeds their commitment to understanding the way that local professionals live and work. The epitome of this approach is "trauma training," where local professionals are plucked from their jobs and put in classes taught by "international experts." Such activities are bound to fail because they are detached from the actual delivery of services. A contact perspective encourages professionals to relinquish the role of colonizer (in the guise of international trauma mental health expert) and to encourage processes of dialogue and translation that increase the expertise and authority of local psychiatric and community leaders. For example, in Kosova, the University of Illinois at Chicago and The University of Pristina formed a collaboration that supported the Kosovars in developing and implementing a plan for development of mental health services. A professional-to-professional initiative, the Kosovar Family Professional Education Collaborative, has been helping Kosovar professionals to develop professional identity and expertise that builds upon Kosovar cultural values concerning the family.

These are examples of how the contact zone and other new teachings in ethnography may open up vistas for refugee mental health services that move away from ineffective or exploitative practices and toward interventions that better fit the needs and strengths of refugee families and the professionals that serve them. These and other implications of the new ethnography are not limited to refugee mental health, and further deliberations on their usefulness to other refugee health services should be pursued.

References
1.
Clifford  J An ethnographer in the field. Coles  Aed.Site-Specificity: The Ethnographic Turn London, England Black Dog Publishing2000;52- 71
2.
Weine  SMRazzano  LMiller  K  et al.  Profiling the trauma related symptoms of Bosnian refugees who have not sought mental health services. J Nerv Ment Dis. 2000;188416- 421Article
3.
Clifford  J Routes: Travel and Translation in the Late Twentieth Century.  Cambridge, Mass Harvard University Press1997;
4.
Weine  S When History Is a Nightmare: Lives and Memories of Ethnic Cleansing in Bosnia-Herzegovina.  New Brunswick, NJ Rutgers University Press1999;
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