0022-3018/01/1898 –507 Vol. 189, No.

8
THE JOURNAL OF NERVOUS AND MENTAL DISEASE Printed in U.S.A.
Copyright © 2001 by Lippincott Williams & Wilkins

Traumatic Experiences and the Mental Health of Senegalese Refugees

SHARON S. TANG, M.S., and STEVEN H. FOX, PH.D.1

The purpose of our study was to conduct a preliminary investigation into the
experiences and mental health of Senegalese refugees. Although research has
established that refugees are more prone to psychiatric illnesses than the general
population, little has been written about West African refugees. Our focus was on
adult refugees (18 years of age and older) from the Casamance region of Senegal. A
total of 80 participants (39 women, 41 men) were randomly selected from refugee
camps in The Gambia. The Harvard Trauma Questionnaire and the Hopkins Symp-
tom Checklist-25 were used to assess levels of traumatization and mental health
status. Typical of refugees of war, participants reported suffering a large number of
various traumas. High prevalence rates of anxiety, depression, and posttraumatic
stress disorder were also found in this group. A substantial mental health problem
exists within the Senegalese refugee population that may signify a potential human
crisis.
—J Nerv Ment Dis 189:507–512, 2001

The responsibilities of health care professionals
are broadening in range such that they now embrace
humanitarian crises, war, and violence. Recently,
the long arm of health care has extended to touch
even the realm of genocide (Willis and Levy, 2000).
The evolving responsibilities of health professionals
include documentation of human rights violations
occurring in these contexts. Such documentation
may provide early warning of impending human di-
sasters as well as crucial evidence in establishing
responsibility for criminal acts and the need for and
direction in which to point reforms (Iacopino and
Waldman, 1999). This represents critical information
for policy makers, prosecutors of war crimes, and
the public. Health care professionals can offer a
unique contribution to the investigation and docu-
mentation of human rights issues in the context of
health effects on vulnerable populations and individ-
ual victims. Health-related information may produce
evidence of human rights abuses that is more cred-
ible than standard methods of case reporting
(Geiger and Cook-Deegan, 1993).
In the spirit of the expanding role of health care
professionals in documenting human rights abuses,
we present a study of the trauma events and psychi-
atric sequelae of a sample of West African refugees
from the Casamance region of Senegal. The findings
1
New Mexico Highlands University, Department of Behavioral
Sciences, Las Vegas, New Mexico 87701. Send reprint requests to
Dr. Fox.
The authors would like to thank Mr. Alade Joiner, UNHCR
National Officer in The Gambia, for his foresight in requesting
this study.
presented may well serve as early warning of an
impending crisis within a civilian population.
For nearly two decades, fighting in the Casamance
region of Senegal between the separatist movement,
Mouvement des forces democratiques de Casa-
mance (MFDC), and government troops have terror-
ized civilians. Hundreds of cases of torture, extraju-
dicial executions, kidnappings, and detention of
political prisoners by the Senegalese government
have been documented by Amnesty International
(1998), even though the constitution offers full guar-
antees for the protection of human rights. Evidence
of the murder and torture of civilians by the MFDC
was also apparent. However, the strength of Am-
nesty International’s evidence is limited by their ex-
clusive reliance on qualitative case reporting.
As a result of this obscure, underreported, and
sparsely documented conflict, thousands of Senegal-
ese have fled the southern region, crossing the
nearby Gambian border to find sanctuary. The ma-
jority are estimated to be staying with relatives in
the urban area of Banjul (United Nations High Com-
missioner for Refugees [UNHCR], 1998). However,
those without such recourse must live in the refugee
camps managed by the UNHCR (1998). The current
study focuses upon this camp population.
Research has found refugees to be at greater risk
for suffering from psychopathology than nonrefugee
populations (Boehnlein and Kinzie, 1995a; Ekblad
and Roth, 1997; Williams and Westermeyer, 1986).
Major depressive disorder is one of the most com-
mon diagnoses, with studies reporting its occur-
rence in 29% of Afghan refugees (Mghir et al., 1995)

507
508 TANG AND FOX
and as many as 96% of Cambodian refugees (Carlson
and Rosser-Hogan, 1991). Kinzie (1989) found that
approximately 20% of the 600 patients seen at the
Indochinese refugee clinic in Oregon had been hos-
pitalized as a result of depression with suicidal risk.
A refugee camp survey of 993 Cambodians by
Mollica et al. (1993) reported 55% were symptomatic
of depression and 15% of posttraumatic stress dis-
order (PTSD), another common diagnosis among
refugees.
Despite the growing body of mental health re-
search concerning refugees of various ethnic back-
grounds, little is known about the experiences and
symptom presentation patterns of African refugees,
who constitute about one third of the world’s refu-
gee population (UNHCR, 1998). Indeed, a study of
Sierra Leonean refugees reported by us represents
the only work addressing trauma events and mental
health among West African refugees (Fox and Tang,
2000). Already, other cultures have been found to
differ from each other in experience and symptom
presentation. For example, in a clinical sample,
Kinzie et al. (1990) found the prevalence rate of
PTSD to vary widely among Indochinese ethnic
groups with the Mien having the highest rate at 95%,
Laotians at 65%, and Vietnamese at 53%. Such vari-
ation may reflect differing educational and socioeco-
nomic backgrounds, as well as traumatic experi-
ences among the groups. In addition, although
avoidance behavior has been observed to be com-
mon among Southeast Asian refugees and may even
be a therapeutic means of alleviating distress for
them (Kinzie, 1989), research with a group of Salva-
doran women refugees disclosed the absence of
avoidance (Jenkins, 1996).
Similar research is necessary among African ref-
ugees to determine similarities and differences with
Western definitions of PTSD, anxiety, and depres-
sion. Such knowledge would be of direct benefit to
mental health workers in refugee camps in assessing
and treating these illnesses. The purpose of our
study was to conduct a preliminary investigation
into the experiences and mental health of Senegal-
ese refugees.
Methods
Participants and Procedure
The study was conducted at the request of the
UNHCR national officer in The Gambia and centered
around two camps containing refugees from Sene-
gal. The focus was on adult refugees (18 years of age
and older) whose primary residence was represen-
tative within the camps. Upon arriving at each of the
sites, we conducted a planning meeting with the
respective refugee camp committees. At these initial
meetings, we explained the mission of the study on
behalf of the UNHCR as well as our limitations in
not being capable of providing much financial or
medical assistance, although we did so when possi-
ble. At both camps, the refugee committees volun-
teered to be responsible for arranging interview
times with the selected participants.
The UNHCR representative had given us the most
current lists of refugees residing within the camps.
Based on an estimate of the number of cases that
could be realistically completed in the allotted time,
we determined that every third name on each of the
two sampling lists would be chosen for inclusion in
the study. The starting point on each list was ran-
domly selected. In those few cases where a desig-
nated participant was not available or unwilling to
be assessed, we randomly selected either the previ-
ous or following case appearing on the list.
The total number of potential participants be-
tween the two camps that comprised the sampling
frame was 242 (121 men and 121 women) from
which a total of 80 were randomly selected for in-
clusion in the study. Of those 80 participants, 41
were male and 39 were female. Written informed
consent was obtained from participants after each
was provided with a complete description of the
study, which emphasized their freedom to withdraw
at any time without penalty.
Interviews of participants were conducted in var-
ious predetermined locations within each of the two
camps. Such locations were chosen for their relative
privacy so as to ensure maintenance of confidenti-
ality. Interviews were performed by the first author
(a graduate student of clinical psychology), the sec-
ond author (a clinical psychologist with many years
of research experience in West Africa), and a Gam-
bian community health nurse. Interpreters were em-
ployed in cases where a participant did not share a
common language with the researcher. In prepara-
tion for the interviews, they were trained with par-
ticular emphasis on technical and perhaps obscure
and culturally idiosyncratic concepts. At the conclu-
sion of each interview, we debriefed the partici-
pants, provided an opportunity for them to pose
questions, and gave information regarding how to
contact us in the future.
Measures
We used several questionnaires for the interviews.
A participant data form was used to gather sociode-
mographic information. Two additional instruments
were used to determine the types of traumas expe-
 SENEGALESE REFUGEES 509
rienced by the Casamance refugees and assess their Data Analysis
mental health status. These were the Harvard
To obtain the clinical picture of the Casamance
Trauma Questionnaire (HTQ) and the Hopkins
refugees, frequency distributions and descriptive
Symptom Checklist-25 (HSCL-25). As many of the
statistics (means and standard deviations) have
participants either did not speak or read English, we been determined for such types of data as sociode-
administered the questionnaires verbally with the mographic information, HTQ scores, and HSCL-25
aid of interpreters. Boehnlein and Kinzie (1995b) scores. A MANOVA was used to determine the pres-
note that although self-rating scales, such as the ence of gender differences in the various scores.
HTQ and HSCL-25, are simple to use, they, too,
found it necessary for an interviewer to administer
Results
them due to high rates of illiteracy among their
Cambodian participants. Demographic Characteristics
The HTQ is a cross-cultural self-report instrument Of the 80 participants, 39 (48.8%) were female and
designed for the assessment of trauma and torture 41 (51.2%) were male, with an overall mean age of
related to mass violence and their psychiatric se- 41.3 years (SD ! 15.9). The mean length of time
quelae. It was developed by Mollica et al. (1992) to since arriving in The Gambia was 34.0 months, al-
identify trauma symptoms associated with the In- though there was wide variation (SD ! 19.1).
dochinese refugee experience. Due to its cultural Women generally had received almost no formal
sensitivity, the authors were of the opinion that the education (mean ! 0.5 years, SD ! 1.1), whereas
HTQ might prove useful in the assessment of other men usually had received several years (mean ! 3.4,
traumatized non-Western populations. It includes a SD ! 3.9). The majority of participants was Muslim
16-item checklist of traumatic events as well as a (90.0%, N ! 72), of Jola ethnicity (68.8%, N ! 55),
symptom checklist that combines PTSD criteria and from a rural area (65.0%, N ! 52). Most of the
from the DSM-III-R with Southeast Asian idioms of participants were also subsistence farmers or un-
distress. From this section arises a PTSD score that skilled laborers (72.6%, N ! 58). It is important to
is based upon only the DSM items and a Total score note that only three of the participants (3.8%) re-
that is an aggregate of all the items of the section. ported any psychiatric history before becoming a
In regard to the two symptom scores of the HTQ, refugee. From this statistic, we can infer that subse-
Mollica et al. (1992) determined that the critical quent difficulties with mental health were most
cutoff score above which was indicative of diagnos- likely due to the traumas suffered in the war and to
able PTSD was 2.5 on a scale of 1 to 4. This cutoff other aspects of the refugee experience such as
was determined according to data gathered with living in a camp.
Indochinese refugees. Therefore, although reliability
and validity of the HTQ have been found to be high Traumatic Experiences
in relation to this population, they may be affected
by application to a West African sample. As indicated by the HTQ, most of the participants
The final component of the survey interview con- had been separated from family with whom they had
sisted of the HSCL-25, a self-report inventory ad-
TABLE 1
dressing anxiety and depression symptom clusters. Prevalence of Traumatic Events Experienced—HTQ (N ! 80)
First developed in 1954 by Parloff et al., it was later Event Percent N
adapted into a shorter version by Mollica et al. in
Forced separation from family members 77.5 62
1987 and shown to be a reliable and valid measure Lack of food or water 76.3 61
for Southeast Asian refugees. Mollica et al. esti- Combat situation 51.3 41
mated the critical-cutoff score of 1.75 to indicate the Being close to death 47.5 38
presence of clinical depression or significant emo- Murder of family or friend 46.3 37
Lack of shelter 46.3 37
tional distress. Again, application of cutoff scores to Ill health without access to medical care 31.3 25
West Africans is yet to be established. Unnatural death of family or friend 28.8 23
It has been noted that both the HTQ and HSCL-25 Lost or kidnapped 28.8 23
have proven to be user-friendly, relatively nonthreat- Forced isolation from others 25.0 20
Serious injury 17.5 14
ening, and readily accepted by participants (Mollica
Torture 16.3 13
et al., 1987; Parloff et al., 1954). Such characteristics Imprisonment 13.8 11
in conjunction with their apparent cultural sensitiv- Murder of stranger 10.0 8
ity made these measures among the most appropri- Brainwashing 2.5 2
ate instruments available. Rape or sexual abuse 1.3 1
510 TANG AND FOX

TABLE 2 TABLE 3
Prevalence of PTSD Symptoms (DSM-III-R; N ! 80) Prevalence of Depression Symptoms—HSCL-25 (N ! 80)
Symptom Percent Symptom Percent
Recurrent thoughts or memories of the most Feeling everything is an effort 66.3
hurtful or terrifying event(s) 62.5 Worrying too much about things 63.8
Sudden emotional or physical reaction when Feeling low in energy or slowed down 48.8
reminded of the most hurtful or traumatic General body paina 39.2
events 48.8 Body heata 38.0
Avoiding activities that remind one of the Feeling worthless 36.3
traumatic or hurtful event(s) 42.6 Poor appetite 32.5
Feeling as though the event(s) is happening Feeling no interest in things 28.8
again 42.6 Feeling lonely 28.8
Avoiding thoughts or feelings associated with the Feeling blue (sad) 27.5
traumatic or hurtful event(s) 41.3 Difficulty falling asleep or staying asleep 27.5
Trouble sleeping 32.6 Loss of sexual interest or pleasure 25.0
Less interest in daily activities 27.5 Feeling trapped or caught 13.8
Difficulty concentrating 22.6 Blaming oneself for things 7.5
Recurrent nightmares 21.3 Crying easily 2.5
Feeling on guard 16.3 Thoughts of ending one’s life 0.0
Feeling like one does not have a future 16.3 a
Experimental items.
Unable to feel emotions 12.5
Feeling jumpy or easily startled 11.3
TABLE 4
Feeling irritable or having outbursts of anger 10.1
Prevalence of Anxiety Symptoms—HSCL-25 (N ! 80)
Feeling detached or withdrawn from people 7.6
Inability to remember parts of the most Symptom Percent
traumatic or hurtful event(s) 2.0 Faintness, dizziness, or weakness 35.0
Headaches 32.5
Heart pounding or racing 28.7
Feeling restless, can’t sit still 15.0
been living in Senegal (see Table 1). Most had also Nervousness or shakiness inside 15.0
experienced a lack of food or water. Other quite Feeling tense or keyed up 13.7
common traumas included exposure to combat, feel- Feeling fearful 13.7
ing close to death, the murder of a family member or Spells of terror or panic 12.5
friend, and lack of shelter. Although only 1% of the Suddenly scared for no reason 11.2
Trembling 6.2
sample reported experiencing or witnessing sexual
abuse, it may be that respondents were reluctant to
report such traumas. Anxiety and 58.8% (N ! 47) for Depression.
Of the 16 items listed as traumas, the average MANOVA results indicated that in all cases there
number that participants had been exposed to in any was no significant difference among the scores of
form (i.e., heard of, witnessed, or personally expe- women and men.
rienced) was 11.28. The average number of only The prevalence with which each symptom item
those events personally experienced was 5.11. In was endorsed appears in Tables 2 to 4. Among the
general, men (mean ! 6.02, SD ! 1.9) had experi- depression symptoms, we added two cultural idioms
enced more traumas than women (mean ! 4.15, of distress based upon our own prior observations
SD ! 1.8; t[78] ! 4.52, p " .001). of West Africans. “General body pain” is a nonspe-
cific sense of physical discomfort, as is “body heat.”
Anxiety, Depression, and PTSD As the equatorial climate is quite warm and malaria
is endemic to the region, such complaints were re-
On the HTQ, the average PTSD score was 1.96 corded only when these factors were ruled out. Of
(SD ! .42) and the average Total score was 1.82 the PTSD items, the three most endorsed symptoms
(SD ! .34). Although 10.0% (N ! 8) of the sample represented each of three factors that comprise the
scored above the a priori critical cutoff for PTSD, DSM definition: reexperiencing, arousal, and avoid-
only 1% (N ! 1) did so with the Total score, perhaps ance. However, some items, such as difficulty recall-
indicating that the addition of the Southeast Asian ing the traumatic event and feeling detached from
cultural items produced a less sensitive measure of others were weakly endorsed.
distress. On the HSCL-25, the mean Anxiety score
was 1.75 (SD ! .56), and the mean Depression score
Discussion
was 1.92 (SD ! .48). Many more had scores that fell
above the critical cutoff on this instrument than did Multiple types of exposure to a variety of traumas
on the HTQ, with 46.3% (N ! 37) doing so for appeared to be the typical experience of most par-
 SENEGALESE REFUGEES
ticipants. This is unfortunately consistent with ex-
isting literature concerning refugees of war (Allodi
and Stiasny, 1990; Carlson and Rosser-Hogan, 1991;
Mghir et al., 1995). However, the data reported here
provide only a numerical sketch of the actual suffer-
ing that occurred, as the HTQ does not document
the frequency with which a traumatic event was
personally experienced nor the duration of each
event. For instance, lack of food or water seemed to
be a chronic condition for most refugees, beginning
from the flight from Senegal to their current stay in
the camps. Incidents of beatings and torture were
usually reported as not single occurrences but wide-
spread and repeated.
Among the depression and anxiety symptom
items, both somatic and psychological symptoms
were well endorsed. The endorsement of both types
of items supports Beiser’s (1985) theory that depres-
sion as a disease appears to be quite similar to the
DSM definition throughout various cultures. How-
ever, Beiser also notes that depression as an illness,
that is, the subjective experience and reporting of it,
may vary greatly. For example, despite the high
rates of diagnosable depression, feelings of guilt,
and suicidal ideation were rare. This is consistent
with prior cultural studies that report low preva-
lence rates of suicide and guilt secondary to depres-
sion among non-Western cultures (Boehnlein, 1987;
World Health Organization, 1983). However, feeling
worthless was endorsed by approximately one third
of the sample. This may likely reflect an interpreta-
tion of “worthlessness” as material wealth as op-
posed to self-esteem level.
In addition, the two cultural symptom items that
we added, body heat and general body pain, were
among the most highly endorsed of the symptom
items. They may indicate a tendency to somaticize
emotional distress in a diffuse manner, similar to
Ebigbo’s (1986) findings of nonspecific sensations of
heat among Nigerians.
One would expect that because men had experi-
enced more traumas than women, their average
symptom scores would be correspondingly higher.
Such a dose-response relationship has been re-
ported in numerous studies of refugees (Carlson and
Rosser-Hogan, 1991; Ekblad and Roth, 1997; Mghir
et al., 1995). However, we found no difference in
symptom scores between women and men. It is
possible that, for an equivalent level of exposure to
trauma, refugee men are less likely to experience
symptoms of mental distress. Among Southeast
Asian refugees, Kinzie et al. (1990) have observed
that female gender is associated with a higher prev-
alence of PTSD. One explanation may be a differ-
ence in understanding the course of events that led
511
to becoming a refugee and perceiving some control
over them. During our interviews, many women ex-
pressed that they did not understand why they had
become victims of war, or why soldiers suddenly
appeared in their homes. Men, on the other hand,
tended to have firm opinions on the political situa-
tion, regardless of which side in the war they sup-
ported.
Furthermore, in our sample, most women re-
ceived no formal education, whereas most men re-
ceived at least several years. This can mean the
difference between literacy and illiteracy, and can
influence the ability to organize and learn new in-
formation. McNally and Shin (1995) have shown that
cognitive ability may play a role in the ability to cope
with trauma. Further studies are needed to under-
stand better the influences of gender and level of
education as predictors of anxiety and depression in
refugees. Of course, many other factors, such as
gender roles in the family, coping style, and degree
of acculturation may also play an important role in
mental health outcome.
Other directions for future research should also
include developing a scale with norms designed spe-
cifically for West African cultures that will most
likely include a mixture of the DSM symptoms and
cultural idioms of distress with new validation of
cutoff criteria. As mentioned earlier, the cutoff
points for the HTQ and HSCL-25 were derived for
use with Indochinese refugees and may thus com-
promise the validity of our findings with the Senegal-
ese. For example, the results indicate that the South-
east Asian model for PTSD as presented by the HTQ
lowered the overall PTSD scores. However, if we
assume the HTQ as an instrument is not sensitive
enough, then the direction of error is an underesti-
mation of the number of people experiencing severe
emotional distress. With this in mind, as well as the
fact that, according to the DSM-IV, the prevalence of
PTSD in the general U.S. population is approxi-
mately 3%, the prevalence rates found among the
Senegalese in this study are extremely high.
The alarmingly high rates of psychiatric distur-
bance among this sample of refugees must serve as
warning of a potential crisis in a civilian population.
The disturbingly high rates of trauma exposure pro-
vides powerful evidence of human rights abuses.
Researchers and clinicians alike have an obligation
to focus more attention on those who are underrep-
resented in current studies but who at the same time
have suffered greatly and are in urgent need of
humanitarian aid and health care. And in fulfilling
this obligation, credible evidence of human rights
abuses and impending crises can be accumulated
512 TANG AND FOX
and ultimately influence policy making, prosecution
of war criminals, and public awareness.
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