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The First Encounter

The Treatment Setting

Refugees and torture survivors are generally unfamiliar with Western psychiatric and mental health practitioners. In general, physical symptoms are the domain of medical physicians and native healers; emotional symptoms are most appropriately brought to family, friends and religious healers. Because of this, whenever possible HPRT has located its mental health services in the primary health care system with strong ties to traditional healing practitioners and methods.

The Initial Interview

The initial psychiatric interview should consist of “guided” open-ended questions because many traumatized patients are easily overwhelmed by the intensity of their emotional response to the examiner’s questions.

Despite such an approach, a semi-structured comprehensive mental status examination may still yield little information because refugees can be especially shy, reticent and unable to articulate their feelings. To overcome this problem, HPRT hasdeveloped and validated several screening instruments: the refugee versions of the Hopkins Symptom Checklist-25 (HSCL-25) and the Harvard Trauma Questionnaire (HTQ). The refugee seems to be better able to respond to psychological questions that appear in the form of a medical test, rather than questions asked of them during a personal interview. Screening instruments allow patients to “put words” around their feelings of anxiety, depression, and trauma-related symptoms, without reliving the trauma experience through a personal interview in which the trauma experience is described. The HSCL-25 and HTQ are best introduced into the latter part of the psychiatric evaluation once trust has been established in order to guide diagnosis and treatment.