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The Psychopathology and Prognosis of the Elderly Cuban Refugee

Personal Experience with CubanRefugees and a review of the Literature

Ramon A. Boza, M.D.

Associate Professor,Department of Psychiatry and Behavioral Sciences, University of Miami - Voluntary Faculty, Ambulatory Psychiatry Miami, Veteran's Affairs Medical Center.

Teresita Boza Fernandez, LCSW

Miami Veteran's Affairs Medical Center, Department of Social Work Services

Introduction
Methods
Clinical Observations
Symptoms
Outcome
Treatment Approaches
Discussion
Summary
References

Introduction

The twentieth century witnessed major waves of forced emigration, exile, expatriates and refugees. What follows is a snapshot of a specific group within a specific time frame (1967-1987). However, our observations may also apply to the pre-Holocaust European Jew, the massive, forced immigrations within the former USSR, the defeated loyalist elderly from the Spanish Civil War, the Vietnamese, Cambodian, Bosnian, Rwandan, the Kosovars and so many others exposed to the cataclysmic social forces that have sculpted out era. We decided also to compare our finding with relevant literature found in MEDLINE up until July 1999.

Methods and Demographics

From 1959 to 1985 close to 700,000 Cuban exiles came to the United States, and between 1983 and 1995, more than 1.2 million refugees have entered the United States from different countries. In this article we focus on the clinical management and observations of a limited sample of 28 Cuban elderly (age range 64-82) during the 1967-1987 period. Of these, 22 of them lived in the Baltimore-Washington area and the rest in the Greater Miami area. Nineteen were women, nine were men. Three women lived alone, the rest formed part of the extended family net, residing with their spouses and/or their middle aged children. Some of the patients were acquaintances of the authors through their immediate relatives. In eight instances referrals were made by their family physicians, the remainder was either self referred or brought at their family's request. These patients could be broadly considered to be from a middle class background. All were Caucasians, eleven were professionals, but none were working as such. Of the group, four of them were working on a part time basis, primarily clerical jobs, although some of the women did household supportive jobs. Twelve received Welfare Support (or the previously named Cuban Refugee Assistance Program). All of them, could be regarded as "well-taken care of ", by their children who had preceded them in exile.

All of them became psychiatrically symptomatic within two years of their exile. None were in any real or imagined "dire" need, as earlier reported by Chung and Bemak (1). Fifteen of the patients were married, nine were widows. Two women had never been married, and two had been divorced for years. There were no widowers. Seven had some proficiency in the English language. They were a reasonably healthy group and only three had previous brief psychiatric treatment. All of the individuals were baptized Catholic, but only twelve were practicing. All of the individuals were voluntary refugees, none had been subject to physical torture, thought the majority had been exposed to social harassment, and considered older members of the "lumpen" bourgeoisie class. Lavik, NJ et al. (2) who studied 231 refugees at the Psychosocial Centre for Refugees, University of Oslo, found that 47% could be diagnosed as suffering from post traumatic stress disorder. Apitzsch, et al. (3), discussed a group of Bosnian refugees in Sweden, who, in spite of a good pre-war health history, showed, at the time of their clinical examinations "95% with mental problems, and 39% exhibited medical disease or physical disorders…that required treatment." Eisdorfer, et al. (4) had previously reported on the practical plights, high body concerns, assets, and struggle for autonomy among the American elderly. In our findings we also include some observations and comparisons with other healthy, well-adjusted exiled Cuban elderly who do not form part of this study. We have also incorporated our own observations of differences seen with Anglos of the same age group, as well as with other patients belonging to other ethnic/cultural groups.

This paper is not, and does not pretend to be, a statistical analysis of a randomly chosen sample of elderly Cuban refugees, and does not lend itself to tabulation. It consists only in a series of clinical vignettes and treatment approaches that may be extended to other elderly exiles with similar backgrounds.

Clinical Observations

When seen by us this group of patients showed clear-cut evidence of major dysphoria. Many displayed classic signs of sleep disturbances and psychomotor retardation. Feelings of helplessness were always present, while guilt was conspicuously absent. Some patients voiced their distress with statements of a religious cultural nature. In the majority of the cases (24 out of 28 or 85%), there were somatic disturbances such as headaches, GI disturbances, "pain all over", fears of impending death, fears of developing cancer or having heart attacks, without concomitant findings of actual severe medical problems. All but two patients denied suicidal ruminations, which in many instances were described as "temptations". Llorente, Eisdorfer, Loewensteing and Zarate (5) made an exhaustive study of suicide among Hispanic elderly and found that the male Cuban elderly had a suicide rate 1.7 times higher that elderly male Americans. They reviewed 132 successful suicides among Hispanics for a total of 296 cases in Miami-Dade County between 1990-1993 and found Hispanics had lower educational levels, better social support systems and predominantly chose hanging vs. self-inflicted gunshot (the preferred method among elderly American males.

Interpersonal relations, mostly with the immediate family ad especially with their children, who were using their own coping mechanisms to deal with their own stresses of acculturation. These elderly manifested increasing dependency needs, helplessness, needs of constant reassurance, and in some instances, demanding to be accompanied all of the time. Many did not dare to go out by themselves to nearby shopping centers, churches or for visits. On a few instances, we found evidence of a disguised sibling rivalry in which the competition was with the grandchildren or youngsters of the household. In practical terms, the immediate family needed as much support as the patient did.

Symptoms

In several cases, the beginning of the decompensation was abrupt, with a sudden episode of confusion, mostly at night, that was clinically reminiscent of a TIA or ensuing senility. However, none of these patients continued to deteriorate along these lines, and quite often, this was the only episode of confusion before depression emerged. In one case, which showed distinctive hysterical features, the episode was probably a dissociative one. The patients appeared to respond fairly well to the use of antidepressants titrated to their needs and to the discontinuation of, or non-use of hypnotics and/or minor tranquilizers.

No patient in our sample showed clear cut thought disturbance. Some of the cases displayed an attempt to interpret their predicament within a religious context such as "I have been forsaken by God" and "this is like a living Hell”.. None of the patients questioned the existence of God, but did complain of an emptiness and lack of feeling, even when attending religious services.. Acting out was nil; rather most patients reinforced their rigid standards of behavior. There were no instances of heavy drinking, sexual escapades or overtly hostile behavior. For the most part, there was no cognitive impairment in our patients, they were well oriented and had no over impairment of memory for recent or remote events. In two obsessive patients we observed hypermnesias, with vivid, detailed recall of "a much better past" (6). There was no tearfulness, but a pervasive sense of hopelessness and quiet despair.

All our patients were quite insightful, knowing a great deal about the disturbing psychosocial events they were going through, and were able to quite accurately assess them in their full impact, albeit with a pessimistic taint. Only four of the patients who displayed somatizations appeared to resent the implication of a psychiatric referral.

Outcome

Probably the most disturbing finding was the fate of four of the nine male patients who died within a year of their arrival. Three of them were in reasonably good physical shape, and one had a history of lymphoma, with several years of complete remission. None of them were lacking appropriate medical care, and in fact three of them were closely related to physicians. All four, after a short period of apparent adjustment, began to experience feelings of futility and helplessness. They described themselves as useless and burdensome to their families. All of them denied suicidal ideation or fantasies, but three of them predicted they would die soon. Two of them had premonitory dreams of their death, with no fear attached to it. None of them could project themselves into the future in a constructive way, although one made effort to obtain a job in the health care field. The most important feature was the feeling that there was no role available for them, nothing that could be offered or given that would make life worthwhile. They felt out of step with the culture and their own families. It seemed as if they were already disengaging themselves from relationships and family as previously reported by Cumming (7). The theme of impending death became paramount in their communications and transactions. All their families appeared aware of the seriousness of the situation, the worsening of their psychological condition, the lack of elan, with the concomitant dearth of hard clinical findings. They withdrew from the mainstream of their daily life, and their families and physicians seemed unable to stop their relentless course.

When the end came, it was of no surprise to anyone, one of the wives dreamed of a funeral ten days prior to the death of her husband. Of the four men, one died of a MI, the next died of a sudden massive GI bleed, another died in his sleep, and the lymphoma patient experienced a cataclysmic relapse. In all four men, thee were an element of doom and fatalism, a lack of interest in living that brought to mind the so-called "voodoo death". In their general attitude, and in their own appraisal, there was a factor of self-fulfilling prophecy. One of our patients had been intensely observing a small shrub that had been transplanted to a new plot and made daily excursions to ascertain its progressive wilting and eventual death. He stated "the same thing is happening to me, I have been transplanted to a foreign soil and I will die soon, " which he did shortly thereafter.

Discussion:

The severe stress of exile and the adaptation to a whole new culture, language and mores was handled in differently by the Cuban elderly. It was our impression that the women were better equipped to cope, perhaps because they were able to quickly define their roles as "home-helpers". In general, women showed more resiliency and adaptability. The men, however, came from a background in which they saw themselves as the breadwinner and "paterfamilias". Those men that kept themselves pretty active prior to exile were the ones that felt the most out of step in the youth oriented, fast paced competitive culture. Their egos and defense mechanisms were badly bruised and shattered. The ones who succeeded were those that were able to use some of their previously learned skills, and their former capacity to enjoy leisure was a definite asset (8). One of our male patients, a former dentist, enjoyed carpentry as a hobby and immersed him with home repairs, carpentry and handiwork and managed to adapt remarkably well.

We also noticed that the three patients who had a long history of neuroticism fared better that those who experienced psychological maladjustment for the first time. It was as if they were used to the vicissitudes of neurotic misery and did not perceive it as an unusual or particularly threatening experience. On the whole, the lack of transportation or language skills was serious handicaps. as wee the lack of structures geared toward meeting and sharing with other elderly of similar interests. On the other hand, previous, working knowledge of English and appreciation of the culture appeared to be protective elements from possible decompensation.

Treatment approaches

a) Individual Psychotherapy:

Treatment modality was highly flexible and heterodox with those individual patients who had not had previous psychological interventions. With them, the time and setting of the interview, except the initial one, could vary considerably from case to case. Follow up could be either in the office or in informal settings. Telephone contact was quite frequent and attempted to convey a message of continuity and availability. An educational style was adopted by the therapist, who identified for the patients the process he/she was going through and offered the opportunity to explore possible practical solutions. Identifying the symptoms as an "illness" brought considerable relief to these patients who often expressed fear of being stigmatized by the derogatory connotation that was implied in suffering from "nerves".

The persons who had a lifelong history of neurotic difficulties was dealt with along different lines. We identified the strengths in the patient's neurotic defenses and sought to redirect them in a healthier fashion. Long experience had taught the therapists that these patients, who appeared to cherish their right to complain, did not respond well to supportive statements such as " you look fine today". In fact they were interpreted as to mean that the therapist did not truly understand, or empathize with them. Instead, we found it helpful to listen attentively to the long list of physical and social complaints without interruption or digression on our part. The patients were neither lectured, nor admonished with a Pollyanna review of the positive elements in their lives. To the contrary, the therapist agreed that it must be awful to experience this loneliness and despair and would agree that it seemed a most painful kind of life. Furthermore, we emphasized their anguish was evident in their countenance, body language and attitude. Next, we asked for more symptoms, distresses, and aches that he/she had not yet mentioned, and inquired about them in careful detail. Most often, these patients would appear surprised and made comments such as, "its not that bad!” “Your are making it worse than it really is” .This is the moment to seize and redirect the interview to other areas such as the exploration of real life problems. In our experience, this unorthodox methodology allowed us to build long lasting rapport with our patients, who no longer feared that hey might be ignored or rejected.

b.) Religious beliefs:

The patients relationship with a priest, deacons or member of a church group had a profound meaning at the moment they started to look at, and evaluate their life with different perspective and elements of value judgment. In general the presence of faith itself appeared to be a good prognostic sign in the prevention of a deepening of their stress dysphoric disorder.

c.) Sociotherapies and Preventive measures:

The experience of being forced into unwanted exile, being uprooted from their familiar culture, is a most painful and traumatic experience for the elderly. Therefore, appropriate and individualized support systems are essential to prevent psychopathology in this high risk, vulnerable population. Lowenthal (9) as cited by Eisdorfer, et al. has described the importance of a confidant. The existence of such a relationship is of such importance that it is though to play a larger role than either role status or social stability in the maintenance of good morale. Recent losses can be considerably softened by the presence of the confidant. Consequently, the presence of a health professional, or a peer by whom the patient feels understood, becomes of paramount importance. From a practical standpoint, the implementation, maintenance and expansion of programs that provide the elderly with the opportunity to feel useful, to exercise their criteria and judgment, to give to others, probably bolsters the m oral of the elderly more than any other resource. Recent reports on the Russian refugees (10) as discussed by Chun-Chung et al, showed a similar profile of mental health users - 65% female, 62% suffered from affective disorders and 44% spoke mainly Russian. They were primarily community clinic users and the source of referral was family, friends or themselves.

Organizations that increase or maintain a high level of intellectual activity, that encourage the elderly to keep alive their national history and traditions, entities that allow them to become the "transmitters" of their experience and knowledge to new generations, are one of the most important measures to nurture the psychological stability of the elderly refugee. They do indeed increase their sense of worth, and are the best antidotes to boredom, isolation and decay. Finally, help to the nuclear family in the form of subsidies, respite programs and the like could in many instances avoid institutionalization in convalescent homes. The natural habitat of the Cuban elderly is within the framework of their extended family, with familiar language, food and value systems. We would also advise home care visits provided by "native health worker" to provide appropriate or necessary medical intervention. It is our belief that programs of this nature, in the long run, would be less costly, and provide more appropriate care to the refugee elderly.

Summary:

It would be unwise to extend the experience of a small, select group of elderly exiles to the present universe of aging under the duress of political exile. Being the victims of social upheaval is not the same experience as to barely escape alive from a war-torn country, or to have experienced ferocious genocidal attacks, with the murder or mutilations of one's family and friends. However, once transplanted to a new milieu, the sadness, sense of hopelessness and unexplained lethal outcomes, as seen in some instances, may be very much the same in either case. Within this context , we ought to be concerned with the survival of the exiled, uprooted elderly male, who seemingly are more vulnerable than the members of other gender or age group. The first year after uprooting appears to be critical for successful interventions, Specific programs and further studies will be needed for this high risk population.

REFERENCES

1.- Chung RC, Bemak F - “The Effects of Welfare status on psychological distress among Southeast Assian refugees” - J Nerv Ment Dis (1996) 184: 346-353. 2.- Lavik NJ, Hauff E, Skondral A, Solberg O - “Mental disorders among refugees and the impact of persecution and exile: some findings from an outpatient population” - Br J. Psychiatry (1996) - 169:726-732.

3.- Apitzch H, Erickson NH, Jakobsson SW, Lindgreen L, Lundin T. “A study of post-traumatic stress reactions among war refugees, based on medical records” - Lakartidningen (1996) - 93:4285-8,4291-4

4.- Eisdorfer C, Golann S (Ed). “Mental Health in later Life” (1970) Handbook of Community Mental Health. Appleton-Century-Crofts.

5.-Llorente M, Eisdorfer C, Lowenstein D and Zarate Y. “Suicide among Hispanic Elderly: Cuban-Americans in Miami-Dade County, Florida (1990-1993)” - J Mental Health and Aging- 2:79-87. 6.- Boza R, Milanés F, Hanna G. “Memory Dysfunction” - Resident & Staff Physician (1990) 36:23-28.

7.- Cumming, Elaine and Henry: “Growing Old: The Processes of Disengagement” (1961), New York - Basic Books.

8.- DeGrazia, Sebastiáan - “Of Time, Work and Leisure” (1964) Garden City N.Y.: Doubleday Anchor Books pag 181-206

9.- Lowenthal, MF - “Lives in Distress” - (1964) New York. Basic Books.

10.- Chung-Chung Chow J, Jaffee K, Choi D. “Use of Public Mental Health Services by Russian Refugees” - (1999) - Psychiatric Services (50): 936-940

Last Updated: 11/02/00

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