The Harvard Program in Refugee Trauma (HPRT) was founded as the Indochinese Psychiatry Clinic (IPC) in December of 1981. IPC was initiated as a public experiment to provide the highest level psychiatric care to our local community’s poorest patients, i.e., refugees from Southeast Asia. At the time of the initiation of this clinic there was no public support of refugee mental health. The traumatic life experiences of refugees were unknown to the U.S. general public. The mental health care of non-English speaking communities was on the distant horizon of American medicine. The concepts behind the terms torture, human rights, and cultural competence were in their embryonic state as far as medicine and psychiatry practiced in American were concerned. In spite of this situation, American had since the 1950s a major emphasis on providing high quality services to the poor through community mental health and the development of neighborhood health centers.
It was within the best American tradition of publicly supported health and mental health services that IPC was established at the Brighton Marine Public Health Service in Brighton (Boston) Massachusetts in December of 1981, by a team of mental health practitioners including refugees from Laos, Vietnam and Cambodia. This clinic, which operated within a primary health care center, blossomed into one of the most famous clinics in the U.S. and abroad.
IPC’s clinical and research mission was to provide the highest quality of care to the poorest members of American society—newly arrived refugees. This mission also included placing the mental health concern for refugees and the local, national and international policy agenda. In the early 1980s, the mental health impact of war, torture and mass violence, was completely unknown and consequently neglected by those policy pioneers who had influence over the lives of refugee communities. An essential element of achieving this mission was a science based methodology (see Methodology) that could for the first time describe the trauma experienced by refugees and civilian populations as well as the medical and psychiatric sequelae associated with these events. The discovery and evaluation of culturally effective treatment now called evidence based medicine was always an essential aspect of IPC/HPRT’s working methods. The clinic, especially in its early days, no matter how small its size and budget, always used its clinical experience and knowledge as a springboard to a greater scientific understanding of refugee mental health. This science oriented methodology led to many major discoveries that have transformed the care of refugees and traumatized populations worldwide.
HPRT was not invented “”de novo”” by its founders. HPRT came out of a powerful tradition of public psychiatry rooted in the scientific and clinical traditions of some of the world’s greatest psychiatrists and mental health scholars. Each of the following individuals and movements had an enormous impact on the evolution of HPRT’s clinical, scientific and policy activities. HPRT acknowledges the following individuals and their professional contributions to refugee mental health. In almost all cases the influence was powerful working through the vision of HPRT’s staff.
Upside Down Psychiatry
Professor Douglas Bennett, Maudsley Hospital, England coined the term “”upside down”” psychiatry. Bennett, a close advisor for IPC, was one of England’s leading social psychiatrists after World War II who liberated the seriously mental ill from the mental hospital. Bennett demonstrated that chronic institutionalized patients could not only work in the community, but could lead economically productive lives.
Bennett’s “”Upside Down Psychiatry”” was related to the famous English “”inverse care law”” that stated that those patients in greatest need of health care received the least amount of care and the poorest service. Bennett acknowledging this law in mental health, believed that in order to successfully treat the seriously mental ill patient (most of whom were poor) that you had to take all of the practices of modern psychiatry and “”do the opposite.”” For example, Bennett believed that mentally ill patients would work and live in the community and that nurses and non-professionals could be more helpful to those patients than psychiatrists.
Dr. Bennett, who provided consultation to IPC for almost 20 years until his recent death, strongly encouraged IPC’s innovations such as the use of trained refugees to serve as bicultural workers. His optimism for the most damaged patients helped HPRT develop an effective model of recovery for highly traumatized and tortured patients.
Social Class And Mental Illness
Professor Fritz Redlich, former chairman of Yale Psychiatry and Dean of Yale Medical School, was one of the leading 20th century psychiatrists in America. In 1950, Dr. Redlich conducted a classic study along with the American sociologist August B. Hollingshead that defined the impact of social class on patient care as well as the prevalence of psychiatric disorders.
Called Social Class and Mental Illness, this study revealed that patients from the lower social class received entirely different treatment than patients from higher social classes with similar diagnoses. This study defined the concept of the “”low-status”” patient in psychiatry who in spite of an increased burden of mental illness was marginalized to the fringe of high quality psychiatric care where they received low-contact, drug oriented treatment, primarily from non-professional staff, if they received any treatment at all.
Over the past 50 years, this original mental health disparity between the social classes has been shown to include people of color (e.g., African-Americans), non-English speaking populations (e.g. Hispanics) and refugees and torture survivors. Over the past decade, managed care has intensified this health inequity by excluding mental health care from insurance coverage, reducing psychiatric intervention primarily to brief medication checks, refusing to hire competent interpreters, and eliminating psychotherapy. This shift in financing in America has widened the psychiatric gap between races and classes, since only the wealthy can afford privately funded psychiatric services.
HPRT established itself in 1981 fully realizing that refugees were “”low status”” patients, and that it would have to overcome enormous barriers in order to provide high quality care to these patients. Insights put forth by Hollingshead and Redlich, including the 25 year follow up conducted by Redlich and Mollica (a founder of IPC) helped HPRT/IPC produce successful treatment outcomes in caring America’s new low-status patients—i.e. Southeast Asian refugees.
Professor Redlich remains a strong supporter and advisor to HPRT partly because of his own flight from Nazi Germany just prior to World War II, and his strong commitment as a scholar to understanding the psychological motivations of perpetrators of human rights violations, including leaders such as Adolph Hitler.
In 1980, one of the co-founders of HPRT met Italy’s leading psychiatric revolutionary, Professor Franco Basaglia, during his public lecture in Rome. Professor Basaglia was the head of a national movement called “”Psychiatria Democratica”” (Democratic Psychiatry) that transformed the entire landscape of psychiatry in Italy and Europe. Although Basaglia died shortly after their meeting, HPRT’s director continued to consult to the Italian government (CNR) evaluation of reform for over 15 years. Over its 20 years of activities, HPRT adapted its knowledge of Psychiatria Democratica to providing culturally effective community based mental health care in the United States and abroad (e.g. Cambodia)
Oral History Traditions
In the early 1980s, two women leaders in the development of the women’s oral history tradition in America provided grant and scholarship support to HPRT’s fledgling oral history activities with Cambodian refugees. The late Dr. Pat King and Ms. Sheila Biddle of the Schlesinger Library for the History of Women in America and the Ford Foundation, respectively, helped to initiate HPRT’s Cambodian-American Women’s Oral History Project. The Cambodian-American Women’s Oral History Project went on for over a decade, collecting the oral histories of ten Cambodian women who had resettled in the United States after surviving the Pol Pot genocide (1975-1979). The women oral historians were eventually photographed by a Boston photographer, Marcus Halevi, resulting in a exhibition of photographs and oral history vignettes called “”Courage and Resiliency: Cambodian Women in America.””
Pat King and Sheila Biddle were instrumental in the early days of HPRT, providing the first financial and scholarly support to HPRT’s early research efforts. They helped nourish a visionary seed in HPRT’s early days that developed into a new global approach to the care of survivors of mass violence and torture. In addition, the Cambodian Women’s Oral History Project has come to serve as a major foundation to HPRT’s clinical insights and research activities.
A Pantheon of Brilliant Minds
Five other major scholars and intellectuals have had a major contribution on the pioneering work of HPRT over the past 20 years. These individuals are Professor Boris Astrachan, Professor Eugene Brody, Professor Chester Pierce, Dr. Nina Murray, and Professor Yasushi Kikuchi.
Professor Astrachan is a seminal figure in the development of political and administrative psychiatry in America. His entire career, which includes his professorship at Yale University and chairmanship of the University of Illinois, Chicago, has been devoted to the psychiatric care of poor and disenfranchised patients within the public sector of American medicine. Professor Astrachan, through his ongoing support of HPRT for over 20 years, provided HPRT with the incredible skills, strategies and stamina needed to introduce into American medicine an entirely new field devoted to the refugee patient. Astrachan, similar to Professor Douglas Bennett, strongly advocated for the return of mentally ill patients to active and productive lives. As a realist, however, he also was able to clarify those specific tasks that needed to be achieved in order to transform the psychiatric and medical establishment.
Professor Eugene Brody, former Secretary General of the World Federation for Mental Health and editor of the Journal of Nervous and Mental Disease, introduced HPRT to and facilitated its early role in the global mental health movement. After World War II, WFMH was created as an international mental health organization devoted to the fair and equitable care of the mentally ill as well as fostering world peace. WFMH’s initial founding document “”Mental Health and World Citizenship”” has served as an inspiration to the global activities of HPRT. With the full support of Dr. Brody and WFMH, HPRT has been able to make many significant policy contributions to refugee mental health, including the first major survey of a refugee camp (known as Site 2) the first memorandum agreement between WFMH, HPRT and UNHCR, and the creation of many refugee mental health programs throughout the world through WFMH’s committee on refugees and migrants, run by Dr. Mollica for over a decade. Professor Brody, in addition, has taught and consulted to HPRT as a visiting Harvard professor for almost 15 years.
Professor Chester Pierce, a leading American psychiatrist at Harvard, has contributed his experience and skills in extreme environments to HPRT’s work in the Balkans, East Timor, Africa, and the post-September 11 tragedy in New York City. Professor Pierce has helped guide HPRT’s global vision in the identification, recruitment, training and supervision of primary care and health practitioners throughout the world who are working under violence and resource-poor conditions, caring for the world’s most traumatized citizens. Dr Pierce’s brilliant and provocative insights into the mental health impact of racism has also contributed to HPRT’s understanding of the refugee experience.
Dr. Nina Murray, a child psychologist and international authority on traumatized children, has offered her expertise on HPRT’s research on numerous occasions (e.g., Cambodian refugee children.) Dr. Nina Murray’s strong academic association with her late husband, Professor Henry Murray, along with her own research, allowed her to help frame HPRT’s overall research agenda. Dr. Murray strongly supported HPRT’s scholarly and research activities, especially at times early on when few research dollars were being allocated to refugee mental health and related areas. Yet, in spite of this austere research environment, HPRT’s research activities flourished and were critical to the scientific expansion of this field, leading to many new and important discoveries.
Professor Yasushi Kikuchi is one of Japan’s leading cultural anthropologists. Professor Kikuchi, in addition, helped to establish the field of development anthropology in Japan. Recently he designed and directed Waseda University’s new graduate school, the Waseda Institute for Asian and Pacific Studies (WIAPS). Professor Kikuchi has to HPRT a strong appreciation of the role of culture and development anthropology in the field of refugee mental health. In 1995, a few days after the Kobe earthquake, he helped bring an HPRT team into the earthquake zone. HPRT and WIAPS, through Professor Kikuchi’s mediation, have had a major impact on mental health policy and disaster relief in Japan. Professor Kikuchi has remained a strong supporter of HPRT’s activities with ministries of health in conflict/post-conflict societies as well as those dealing with natural disasters (e.g. Japan/Turkey) and terrorism (e.g. Peru).
HPRT’s creative vision and activities over the past 20 years have grown out of the brilliant and generous support of these men and women. Each helped to nourish and guide HPRT in spite of limited early support and criticism. Without their assistance, HPRT could not have achieved its global impact on the science and care of traumatized populations worldwide.