Mental Health Issues of Resettled Refugees (Mental Health Care Needs of the Refugee After Relocation)

Mental Health Issues of Resettled Refugees

Mental Health Care Needs of the Refugee After Relocation

A refugee is someone who has crossed international borders fleeing war or persecution for reasons of race, religion, nationality, or membership in particular social and political groups and are protected by several international conventions (Toole & Waldman, 1993). The number of refugees and internally displaced persons in need of protection and assistance has increased from 30 million in 1990 to more than 43 million today. War and civil strife have been largely responsible for this epidemic of mass migration that has affected almost every region of the planet (Toole & Waldman, 1993). Refugees are a particularly vulnerable population that is at risk for mental health problems for a variety of reasons: traumatic experiences in and escapes from their countries of origin, difficult camp or transit experiences, culture conflict, and adjustment problems in the country of resettlement, and multiple losses-- family members, country, and way of life (Lipson, 1993).

Mental Health Care Needs of the Refugee After Relocation

Nowhere are the health care needs of refugees more pronounced than in the realm of mental health. Refugees are vulnerable to psychological distress due to uprooting and adjustment difficulties in the resettlement country, such as language, occupational problems, and cultural conflict. Uprooting creates culture shock, a stress response to a new situation in which former patterns of behavior are ineffective and basic cues for social intercourse are absent (Lipson, 1993).

The clinical and research literature shows a significant degree of psychological stress among refugees with relatively high levels of physical and psychological dysfunction during the first two years of resettlement; after three years, there was some improvement and increased adaptability, but there was still serious and pervasive adjustment problems affecting some sectors of the refugee population, such as high levels of somatization, depression, and post traumatic stress disorder. These symptoms have even been noted five years after resettlement (Lipson, 1993 & Chung & Kagawa-Singer, 1993).

The Importance of the Family

Studies have shown that much of the depression and anxiety of refugees can be alleviated if they can keep family ties somewhat intact and can develop social networks with others from their culture (Beiser, et. al, 1989, Beiser, et. al., 1993, Allden, et. al., 1996, Buchwald, et.al., 1993, Baker, et. al., 1994, & Carlisle, 1995). Other studies, however, have shown that while family can be a valuable source of emotional support, immigrant families can also be too overwhelmed by their own immigration demands to provide support or can generate additional stress for their members (Aroian, et. al., 1996).

Initial Assessment

Mental health providers should elicit their refugee client's immigration history: length of time in the country, circumstances of flight and first asylum, and who and what was lost. This information is critical for understanding client's adjustment and problems, such as identifying post- traumatic stress disorder (PTSD). It is important to assess for specific symptoms of PTSD and whether they are being confused with other symptoms, such as grieving, losses of family, country, and lifestyle, depression associated with downward social status and inability to find work (Lipson, 1993).

Torture

A major issue in treating the refugee population is the subject of torture. Many refugees come from parts of the world where torture is still prevalent. This population suffers from significant problems besides those that effect other refugees. Torture survivors suffer from high levels of depression and anxiety with "existential" aspects that are not a part of the traditional schemata; these may be reflective of a more subtle and specific aspect of psychopathology or may be part of a more pervasive problem of "complex PTSD." Psychotic symptoms and suicide attempts are relatively frequent; these constitute severe problems which led to psychiatric assessment and treatment. Domestic violence, aggression, alcohol problems, and psychological disorders among the children of survivors are also frequent concomitants of formal psychiatric disorders in torture victims (McGorry, 1995 & Silove, et. al., 1993). These symptoms have been found to be consistent across cultural and gender lines (Fornazzari & Freire, 1990 & Petersen, et. al., 1994). Another significant aspect of the symptomatology of torture victims is that the effects are more pronounced in those who become refugees than in those who stay in their own country (Kantemir, 1994).

Traditional psychiatric approaches such as individual insight or supportive psychotherapy with psychoactive medications have had a limited success; however support groups for such refugees composed of others from their background and experience appear to be helpful (Lipson, 1993).

The Role of Culture

Finally, the role of culture cannot be emphasized enough. Culture may not only be the glue that holds a group together, it can also be their chief stressor in trying to adapt to new surroundings without losing their own identity or sense of self worth (Hattar & Meleis, 1995).

It is incumbent on health care agencies that will be treating a refugee population to employ members of the refugee community and to look to them for guidance in their approach to the community. The use of traditional healers from the refugee's home culture can assist the refugee in getting access to health care in a culturally acceptable and meaningful way. Traditional healers, in conjunction with western trained health care providers can bridge the gap between cultures and make the transition from cultures smoother (Hiegel, 1983).

In conjunction with the refugee community it is advisable to develop a cultural competence check list. This will assist in maintaining an approach to the community that is culturally sensitive while allowing for the community's health care needs to be met (Dana & Matheson, 1992). It is also necessary to learn to work with and through interpreters. This will require adequate training of interpreter staff. Fluency in the languages of the host country and refugee group is not enough. The interpreter must be knowledgeable of the nuances of both languages and cultures. S/he must also be knowledgeable of the common medical terms and psychiatric terms that will be used and how best to accurately translate them. The health care worker must, on the other hand, not treat the interpreter as a mere "mouthpiece", but as a respected colleague who is to be consulted with (Westermeyer, 1990).

The Cultural Consultant

A relatively new concept is that of the cultural consultant in medicine and psychiatry. In a sense the cultural consultant serves as a bridge between the medical model and the refugee's world view. Ideally, the cultural consultant should have experience and training in health care and should be bicultural and bilingual. Awareness of one's own identity, behavior, and biases is also important. These characteristics can be enhanced by training, e.g., workshops in clarification of values or cross-cultural communication and working with and systematic observation of a good role model. Ultimately the cultural consultant's chief task is to answer the question: "Is this behavior normal?" This question lies at the heart of cross-cultural psychiatry, which must determine normality in its cultural context (Budman, et. al., 1992 & Bulle, 1987).

Conclusion

In conclusion the influx of refugees does not appear to be abating at any time soon. The generalist-trained health care provider is in a unique position to aid the refugee; both in the camps and in resettlement. By establishing a hierarchy of needs and building from a base of meeting the refugee's biological needs and leading to the refugee's psychological needs, the provider can assist the refugee to make the transition to a new homeland while alleviating much of the stress involved. These tasks are daunting, but with compassion, knowledge, and the will to be flexible they can be accomplished.

-Friskila Damaris Silitonga, SKEP, NS, MPH

Mental health of refugees, internally displaced persons and other populations affected by conflict

Mental Health in general and Mental Health of Refugees in particular are priorities of the work of the World Health Organization. Intensified efforts are being made by WHO in order to respond to the mental health needs of one of the most vulnerable groups of today' s world.

In January 1999, it was estimated that there were some 50 million refugees and displaced persons worldwide. To ease discussion the term "refugee" as used herein includes asylum seekers, refugees, internally displaced and repatriated persons, and other non-displaced populations affected by war and organised violence. Of the 50 million refugees only 23 million are protected and assisted by the Office of the United Nations High Commissioner for Refugees. The current lack of international consensus over legal definitions deprives the remainder 27 million people of the same support. The overwhelming majority of refugees are from and in low-income countries; women and children represent more than 50 per cent of the total. Heavier toll is imposed on the most vulnerable: the children including the unaccompanied minors, the orphans, the child soldiers, those detained, the children heads of household; the women and girls survivors of torture and sexual violence and the widows; the disabled, the mentally ill and retarded; also the elderly who are alone.

Some 5 million constitute a group presenting chronic mental disorders (prior to the war) and of seriously traumatised, who would require specialised mental health care had it been available. Another 5 million people suffer from psychosocial dysfunctioning affecting their own lives and their community. The remainder majority are faced with distress and suffering. It is important to remember that refugees’ reactions are normal reactions to an abnormal situations.

Present day conflicts intentionally involve civilian populations. Massive human rights violations impose serious risks on millions of people. The cognitive, emotional and socio-economic burden imposed on individuals, the family and the community are enormous. It is established that an average of more than 50 per cent of refugees present mental health problems ranging from chronic mental disorders to trauma, distress and great deal of suffering.

The number of people affected by wars has increased considerably in the last decades. No matter the causes within a limited period of time and suddenly, millions of people are forcibly displaced (1). To address the mental health needs of such large populations specific management ability and approaches are required. The task becomes even more complex as health and mental health infrastructure, if it ever existed, is destroyed. Also, health professionals are often eliminated.

Given the magnitude of the problem and the lack of resources, individual psychiatric care has a limited impact. This is also stressed in the article herein, related to mental health of Burundi and Rwandan refugees, in Tanzania (2). Community-based psychosocial care must become an integral part of emergency response and of the public health care system created in camps and national services. This will help prevent psychiatric morbidity and accelerate the improvement of the psychosocial functioning of people. Efficiency is increased when the concerned community is involved.

The impact of increased mortality and morbidity will necessitate decades of human and financial efforts. Aggravated poverty endangers survival and maintains dependency. Continued human rights violations, hinders reconstruction, reconciliation, peace and development.

Until recently, traditional emergency response was limited to food, water and shelter. Health and other priority needs are often delayed. Recognition of the mental health needs of refugees is emerging but remain poorly addressed as allocation of resources does not follow. Despite scientific evidence to the fact that conflict has a devastating impact on health and on mental health, the latter is not seen as a priority by many decision-makers.

Angola, Afghanistan, Cambodia, Somalia, Burundi, Rwanda, Sierra-Leone, Kosovo, Chechnya are a few examples of prolonged human destabilisation and psychosocial dysfunctioning caused by traumatic events. Their consequences remain in the personal and collective memory even long after peace agreements and repatriation have been accomplished. Traumatic experiences such as killings, material losses, torture and sexual violence, harsh detention and uprooting, all affect people’s behaviour for generations. Life in overcrowded camps, deprivations, uncertainty over the future, disruption of community and social support networks lead to psychosocial dysfunctioning.

Assumptions, however, to the fact that entire refugee populations become mentally disturbed and are in need of psychiatric care need to be avoided. Psychiatric morbidity and psychosocial dysfunctioning depends on the nature and time span of the conflict, on the level and the rapidity with which resilience will emerge, based on socio-cultural factors, and other environmental parameters. The rapidity of mental health support is critical.

Most theories, instruments and projects in refugee mental health care have been developed in Western countries and are often implemented without the necessary adaptations. The humanitarian impulse of many well-intended people is not always associated with the needed evaluations. Therefore, approaches successful in one region do not always correspond to the needs of other regions, their context and culture. Highly specialised clinical models and techniques address the needs of very few, while the many rarely receive adequate support. Moreover, such models are not sustainable. They increase the dependency of populations concerned as well as of services of host countries upon external support and hamper local capacity building. Responses need to become holistic and multisectoral. Equity needs to be applied in the distribution of financial resources, across the globe, for humanitarian relief and development programmes. Non-mental health professionals need more effective training, technical advice and support, in order to create a strong operational network and improve quality of work; friendly-user tools for monitoring and evaluation need to be standardised and yet keep their cultural relevance to maximise the impact of their efforts and prevent burn-out. In research, cooperation between epidemiology and anthropology will increase transcultural validity of data and responses. Better coordination between mental health players and donors will prevent duplications and waste of resources.

WHO, through its normative and field activities, and in cooperation with concerned ministries of health, with other agencies, collaborating centres, academic and research institutions is trying to remedy some of the current shortcomings. Cooperation is strengthened inter-alia, with the UNHCR and the United Nations Children’s Fund. The same applies to the International Federation of Red Cross and Red Crescent societies and to NGOs, like Médecins du Monde, Enfants Réfugiés du Monde, the Norwegian Refugee Council and others. Work with academic institutions is also being pursued for example with the Disaster Mental Health Institute, University of South Dakota, USA, the Harvard Programme in Refugee Trauma, Harvard University, USA, the faculties of Psychology of Rwanda, of Burundi and others. Internal coordination is improving responses and mainstreaming of mental health of refugees. Cooperation with the refugee community is essential in this work.

A lot remains to be done and the following are a few priority areas of WHO's work:

The WHO/UNHCR manual, Mental Health of Refugees (3), now available in ten languages, is being revised to include current needs and new scientific knowledge. Community-based mental health projects, including development of policy and action plans, are implemented in several countries and are ready for replication. Also, a WHO model training of trainers program was created and field-tested in Rwanda and Burundi; it is ready for replication in other countries in the Great Lakes region and with the necessary adaptations it could be used in other countries. Recently, the WHO Declaration of Cooperation in Mental Health of Refugees and Internally Displaced Populations in Conflict and Post-Conflict Situations (4) was developed in order to improve advocacy, international consensus in policy, programmes and cooperation. Also, the WHO tool for the Rapid Assessment of Mental Health Needs of Refugees, and Displaced Populations and Resources, in Conflict and Post-Conflict Situation (5), is pre-finalised. An instrument on Practical Indicators for Mental Health Project Monitoring and Evaluation and Standards for Professionals (in preparation) is being prepared in cooperation with the Transcultural Psychosocial Organisation, a WHO Collaborating Centre. WHO will organise an international consultation in October 2000, to present these instruments for review and adoption. Then, their translation into several local languages will lead to wide use.

In brief, there is a growing global awareness of the impact of war on the mental health of refugees. International commitment to help is increasing. Certain areas of work need to be further improved. Greater international cooperation and information exchange will remedy the chaos of crisis situations. Given the impact of war on large populations, care on individual basis is not realistic. Community-based psychosocial rehabilitation has to be privileged and integrated in the primary health care services to create sustainable responses. At the earliest possible, people with chronic mental disorders and severe trauma should be detected and treated. Non-mental health personnel, given appropriate technical support, have been efficient in responding to the psychosocial distress of refugees. It is also known that long term mental health responses to crisis can lead to the reconstruction of relevant, effective and sustainable mental health services.

It is strongly hoped that these lessons learned will be used to enable all of us to play an earliest and constructive role in alleviating the suffering of millions of people. Providing the necessary resources, restoring their dignity, giving them hope and confidence in themselves and in the international community to work towards a better future are the unavoidable preconditions for their well-being as well as for reconciliation, development and peace.


-Friskila Damaris Silitonga, SKEP, NS, MPH

Refugee Health: Challenges of Resettlement

Refugee Health: Challenges of Resettlement

Health is one of many challenges refugees face during the transition from their homeland to a new country. Because of the very difficult living conditions refugees are exposed to, they are especially vulnerable to illness and poor health.Life as a refugee is difficult for most of us to fathom: imagine being uprooted from your home because of violence or persecution, moving to a camp for an unknown amount of time, and finally being resettled in another country, far from everything you’ve ever known.A refugee is any person who is outside his or her country of nationality and who is unable or unwilling to return to that country.

This may be due to persecution or a well-founded fear of persecution based on race, religion, nationality, particular social group, or political opinion. The United States has resettled about 2.6 million refugees since 1975, and each year about 70,000 refugees are welcomed into this country.But the road to resettlement is a long one, and there are a number of steps a refugee takes between leaving their home country and arriving in our nation. Health is one of many concerns a refugee must deal with during the long transition process. Because of very difficult living conditions in their home countries, refugees are especially vulnerable to illness and poor health. Refugee camps may also pose difficulties. Conditions in the camp may not be clean and food may be inadequate, leading to poor nutrition.

Before resettlement, refugees also lack a ”medical home.” Thus, they may never have had proper care for chronic conditions.Although the challenges refugees face are daunting, a wide network of organizations, agencies, and services continue to help refugee groups. CDC is among those committed to ensuring that refugees receive quality health screening, treatment, and care. In addition to setting standards for the medical screening of U.S.-bound refugees, CDC also advises states in the medical screening process once refugees arrive in the United States. Overseas, CDC’s Division of Global Migration and Quarantine also has two primary field offices that are involved in refugee health activities. These range from disease surveillance to providing technical assistance to physicians who conduct refugee medical examinations. CDC also works closely with foreign governments, U.S. government agencies, and other health or resettlement organizations to improve the resources and services provided to refugee groups.


-Friskila Damaris Silitonga, SKEP, NS, MPH