Refugee Mental Health Challenges
For me, moving is one of the most stressful life events. I decided to move last December and was in my new place by the end of February. In between I lost 12 pounds in 2 weeks, stopped sleeping, required the use of sleeping pills, and spent a lot of time crying. All this even though I was moving 2 miles away, did not have a date that I had to be out of my old place, had plenty of money, and had a friend to move my things. Truly it is hard to imagine how it could have gone smoother.
Now imagine I had to move not to a different neighborhood but to a different country. I had to do it immediately because my country wasn’t safe anymore. I didn’t have anyone to move my stuff which turns out to be okay because I can’t take most of my stuff. Imagine I had a child or two in tow, that I didn’t have much money, that I didn’t speak the language of the country to which I was moving. Imagine that the move wasn’t my choice and that very few decisions about my future would be my choice.
Refugees have risk factors for mental illness that can be grouped in three categories: pre-migration, migration, and post-migration. In their home country they may have experienced significant personal trauma and community trauma from the situation that caused them to have to leave—invasion, civil war, natural disasters. Once they leave home they are at risk for developing symptoms related to separation from loved ones, exposure to violence, and harsh living conditions. When I was in Grande-Synthe, France I met families who had come from a middle class life in their country of origin living under bushes with their children. Once a refugee arrives in the country where they are seeking asylum they face continued stressors—fear and anxiety about deportation, loss of social status, and unemployment, to name a few.
Levels of depression, anxiety, and Post-traumatic Stress Disorder (PTSD) in refugee populations are higher than in the general population. Part of accepting refugees is accepting the pain and distress they carry with them. It also means accepting that their culture will have their own approach to health, both physical and mental. Some communities have started developing approaches to refugee and immigrant health that considers all of this.
Healthcare providers in both mental and physical health face particular challenges to effectively treating refugees. Language barriers, particularly for refugees who speak an uncommon language, can prevent effective communication. Refugees often speak more than one language so they may be able to get their basic needs met but best practice for health professionals is to communicate with someone in their first language. Many people don’t know health specific terms in their second or third language and are best at expressing their feelings in their first language.
Going to a healthcare professional, especially for mental health, is not part of every culture. Consider the stigma associated with mental health in the U.S. or the U.K. Despite our multiple programs, public service announcements, and public figures drawing attention to the importance of mental wellness, people hesitate to get the care they need. How much less likely is it for someone new to the society to seek help? The most successful services are likely those that are provided in creative spaces rather than an office and incorporate the community.
A community approach to mental health also addresses a confounding issue refugees face. Their family and their community have experienced the same traumas, loss, and stressors that they have. One of the foundational aspects of mental health recovery is strong support system: people you can call to talk about how you’re feeling, people who will cheer you up, people who can distract you, people who will encourage self-care. Of course someone who is also struggling can offer these things but community trauma is a real barrier to recovery. Because we know this, it is critical that our services for refugees include building community resilience. A group therapy model might work better than individual sessions and holding these group sessions in a community center or church rather than a medical center might draw better turnout.
Refugees are also more likely to present with somatic complaints than psychological ones. Although we know that there is a high likelihood of a refugee having psychological distress or a disorder, we cannot exclusively focus on mental health. Physicians need to recognize that a refugee may present with a stomach ache rather than anxiety. They may be more likely to admit to a headache than to anger, depression, or nightmares. Physical health centers that specialize in the needs of refugees are as important to their wellness as the mental health centers. The CDC has said that the most serious health threat for refugees is chronic illness, like heart disease or diabetes. If refugees are too scared, too poor, or too uninformed to know how to get medical treatment for preventative or treatable diseases they can suffer for years unnecessarily.
Finally, even the most well intentioned and culturally sensitive provider will be challenged by the number of cultures from which refugees might be coming. Understanding the political landscape of the country the refugee is fleeing helps to establish rapport early on. It also provides insight into the specific situations or traumas that they might have experienced or witnessed. The challenge with that is that refugees might be coming from a wide variety of situations. A woman fleeing El Salvadorian gangs alone today will not have the same fears (or needs) as a man who came to the United States in the 80s from Cambodia. But they will both be refugees seeking services and the providers need to be prepared for both populations. When we develop specialized centers to provide services—both mental and physical—to refugees we are better able to address these issues. Centers should have brief backgrounds available for providers on the countries refugees are most likely to be from—Syria, Afghanistan, Iraq, Myanmar, South Sudan, Democratic Republic of the Congo, Guatemala, El Salvador, Honduras, Cambodia, Laos, Vietnam.
There is nothing easy about treating refugees, particularly when it comes to mental health. Cities with high populations of refugees should be developing health centers to address both mental and physical health. These centers will need to be creative about engagement because this population, even more than others, will be resistant to engagement in a typical medical setting. Engaging the community will be necessary for the wellness of the individual. People are resilient but they shouldn’t have to be resilient alone.
Article by Claire Ryder
VERVE Operative USA & Humanitarian Activist