Psychosocial distress of Tibetans in exile: integrating western interventions with traditional beliefs and practice

Abstract

A psychosocial care project for Tibetan torture survivor's and other Tibetan refugees suffering from psychological distress was opened in Dharamsala, North India in 1995 by a western non-government organisation (NGO) in collaboration with the Tibetan government-in-exile. The clinic explicitly sought to integrate western and local traditional approaches to healing.

The aim of the present study was to examine the views of key stakeholders of the project in the context of broader cultural and social issues faced by exiled Tibetans. Twenty individual interviews were conducted with ‘officials’ (members of the Tibetan government-in-exile, religious leaders, other community leaders, and senior medical staff), the staff of the project (Tibetan and western) and the clients themselves. The interviews were taped, transcribed, and analysed using a grounded theory approach.

All interviewees considered that mental health was an important issue and that awareness of psychological health in the community had improved since the initiation of the project. Clients and staff of the project, and some of the ‘officials’, believed that it provided a much-needed service and that it effectively and sensitively combined western psychological approaches with local cultural and religious beliefs and practices. However, a majority of the ‘officials’ felt that mental health issues were not a top priority in the competing health needs of the community, and that other ways of dealing with such problems (using traditional approaches or local health services) were adequate. Given these and other factors, the longer-term sustainability of the project appears to be a major challenge.

According to the users and providers interviewed, the current project has developed an important and beneficial psychosocial support service. However, the continuing debate amongst community leaders regarding the place and future of the project suggests the importance of accommodating the views and priorities of all local stakeholders—and focusing on sustainability and capacity building of relevant community members—from the outset of such projects. This includes acknowledging the perceived threat to traditional beliefs and coping strategies—particularly in the context of wider socio-cultural disruption—posed by initiatives seeking to integrate western intervention approaches with local healing resources.

Introduction

Tibet, a politically and economically independent country before 1949, was militarily occupied by the People's Republic of China in 1949 and annexed to China as a province in 1959. This invasion and the resulting loss of independence deprived Tibetans of their rights afforded them by their homeland (Norbu, 1998). The violent persecutions and the atrocities inflicted upon thousands of Tibetans since then are well documented (Rabgey, 1998). Over 40 years of restrictions on religious freedom, repression and political violence have caused large numbers of Tibetans (both adults and children) to seek refuge in neighbouring countries (Servan-Schreiber, Le Lin, & Birmaher, 1998).

It is estimated that over 100,000 refugees are currently in India, Nepal and Bhutan (Central Tibetan Administration 1996, cited in Servan-Schreiber et al., 1998). The journey from Tibet to any neighbouring country is long, fraught with peril and may involve the refugee being exposed to various forms of abuse (Ketzer & Crescenzi, 2002). In addition, many political prisoners have also spoken of the violence and torture they experience whilst being in prison (Ketzer & Crescenzi, 2002). Therefore, many of the Tibetan refugees in neighbouring countries have experienced significant levels of suffering associated with the situation in Tibet.

The total number of refugees and internally displaced persons in the world today is estimated to be over 50 million (Westin, 1999). The majority of these refugees are forced to leave their homes due to war or political oppression (Ager, 1999). The impact of organised violence and forced migration on the mental health and social wellbeing of individuals and communities is increasingly acknowledged (Marsella, Bornemann, Ekblad & Orley, 1994; Desjarlais, Eisenberg, Good, & Kleinman, 1995; Pupavac, 2002). Such studies document increasing evidence of a direct relationship between exposure to violence and mental and emotional distress (Mollica et al., 1998), although the repercussions of organised violence are also acknowledged to be significantly social in nature.

The appropriate response to such social and emotional distress is, however, widely contested (Ager, 2002). The application of western psychotherapeutic approaches and counseling has been suggested as an important intervention in helping forced migrants adjust to their changed situations (Agger, 1997). Ager and Young (2001) suggest that, despite the wide range of alternative approaches advocated, counseling can be generally characterised as a supportive intervention that encourages people to express their experiences and reactions to them. However, the relevance of western ‘talking therapy’ and the focus on psychological functioning of individuals affected by conflict or trauma in non-western settings has been questioned (Desjarlais et al., 1995; Bracken, 1998; Summerfield, 1999). According to Bracken (1998), coping strategies of communities that have experienced traumatic events vary and are constructed according to the local social, cultural and political contexts. In such situations it is argued that local, traditional models and methods should be employed in understanding and addressing the social and emotional distress of forced migrants (Bracken, 1998; Summerfield, 1999).

The integration of western and ‘traditional’ understandings of emotional and social distress within an intervention programme offers a potential resolution to this dilemma (Ager, 1997; Diaz, 1999). While the potential value of such integration of western and non-western approaches has frequently been argued (Honwana, 1999; Ager & Young, 2001) there are, however, few examples of such incorporation of differing approaches within a single service (Ager, 2002). Analysis of examples of such integrated service development is of value for a number of reasons. Given the differing epistemologies and, indeed, broader cosmologies of such approaches (Berkow & Page, 2001) is any form of such integration genuinely achievable? With the power of western discourse and the consequent dangers of hegemonic imposition of western constructs on ‘traditional’ societies (Bracken, 1998; Pupavac, 2002) is any form of ‘balanced’ approach to such integration feasible? Indeed, given the power of globalisation and modernisation (Adelman, 1999) is it inevitable that western approaches will displace more indigenous understandings of health and well-being? Analysis of the project described in the current study is a potentially useful first step in answering such questions.

The TPO (Transcultural Psychosocial Organisation) project in Dharamsala was fully established in 1995 (having been initiated some 4 years earlier) with the specific aim of incorporating Tibetan cultural beliefs and practices within a western-style mental health counselling service (see Ketzer & Crescenzi, 2002). Rather than providing a competing account for suffering and/or healing, the TPO project sought to establish complementary means of understanding such distress, using both traditional attributions and insights from western psychology. The experience of the project potentially provides valuable insights into the challenges and opportunities of attempting such an integration of western and non-western approaches to psychosocial support within a refugee population. This paper reports a qualitative analysis of this attempt at integration based on interviews with a range of stakeholders, including patients, project staff, health workers, political and religious leaders.