Addressing Mental Health Needs of Refugees

Abstract

Throughout history, refugees have alternatively been seen as entitled victims of adversity or as threats or abusers of host countries scarce resources. Within the present globalized context, ambivalent public perceptions of refugees are shattering the protective nature of the post migratory environment in refugee receiving countries. This raises new challenges for refugees’ mental health and calls for systemic responses to address both pre-migratory trauma and losses and post migratory adversities. Recent evidence on the effectiveness of mental health treatment for refugees confirms the utility of trauma-focused psychotherapy and the limits of psychopharmacology for stress related disorders in this group. Training of mental health professionals may improve the quality of care for refugees by deconstructing prevalent prejudices about them and promoting empathic understanding. Mental health professionals may also advocate by providing information about social determinants refugee mental health to policy makers and promoting psychosocial interventions and protective social policies.

Our world is not peaceful and, consequently, 65 million persons worldwide have fled their homes because of war or other forms of organized violence. ¹ For mental health services of host countries, what is now commonly called “the refugee crisis” raises several delicate questions: What is the evidence available to respond effectively to the mental health needs of refugees? To what extent do host countries have the resources to cover these needs? And what are the associated training and advocacy challenges?

These questions need to be situated in the wider picture of the continuity and changes in the refugee phenomenon to understand the degree to which we can rely on previously identified “good practices,” and the domains in which the present situation calls for new strategies.

Permanence and Transformation in the Refugee Phenomenon

Since the adoption of the Geneva Convention in 1951, refugees have alternatively been seen with compassion, as entitled victims of adversity, or as potential threats who could destabilize the established social order in host countries and abuse their scarce resources. These shifts in perception are related to the cultural proximity between the refugee waves and host country majorities, the socio-economic context (unemployment rates), and the number of people involved. ² Within the present globalized context, which is associated with social polarization (“us and them” discourses), and the increasing social hostility around religion ³ and other forms of otherness, refugees are often portrayed as potential criminals and frauds. These perceptions have a direct impact on social policies, access to resources, and public attitudes toward refugees, and challenge the protective nature of the post-migratory environment in refugee-receiving countries. ^{2,4 –6} For example, the well-documented post-9/11 upsurge in direct and structural discrimination toward cultural minorities and migrants caused an increase in the level of stress and uncertainty for refugees, and was associated with re-traumatization. ⁷ The tightening of legal procedures was equally a risk factor for mental health concerns. ⁸ The overall landscape also influences mental health professionals’ and institutions’ attitudes and practices. ⁹ In the last decade, the Canadian Medical Association (CMA) and the Canadian Psychiatry Association (CPA) have advocated strongly to preserve access to health care for refugees in Canada, but the services offered by Canadian clinicians and institutions to refugees remain very heterogeneous, probably reflecting the divide in public opinion toward their entitlement to social protection.

To provide an updated landscape of this new social context, in this “In Review” issue, Hynie examines the recent research on social determinants of refugee mental health. The importance of income, housing, employment, migratory procedures, and discrimination as risk factors for refugee mental health suggest that psychiatrists may improve refugee mental health by supporting a public mental health approach to resettlement.

Good Practices in Refugee Mental Health

Little has changed since the 2011 publication of the CMA guidelines for migrants and refugees, which included recommendations for post-traumatic stress disorder (PTSD), depression, interpersonal violence, child maltreatment, and common mental health problems. ^{10 –13} The 2013 and 2015 updates of the NICE guidelines ^14,15 show that recent evidence does not modify significantly the main recommendations published in 2005. ¹⁶ These updates confirm the utility of specific types of trauma-focused psychotherapy and the limits of psychopharmacology, particularly in children. ¹⁷

As emphasized by Silove and others, ¹⁸ although there are good intervention tools for use with refugee clients, mental health professionals face 2 major challenges. First, in times of resource shortage, it is often impossible to rapidly deliver psychotherapy to large numbers of refugees with PTSD; this limitation invites clinicians to look at innovative avenues to try to provide care. Some emerging evidence suggests that lay staff, who are trained by professionals, may be able to deliver effective interventions, ¹⁹ and that some virtual interventions may have to be considered as options. For example, the Karim chatbot, powered by artificial intelligence, was designed to meet the mental health needs of Syrian refugee youth (https://youtu.be/c3AgGSsAPkM). Implementing new tools, however, requires more evaluative research and a major shift in service models. Second, we are still relatively ill-equipped to deal with complex cases of trauma. This is particularly significant when dissociative phenomena and psychoses are entangled ²⁰ or when a broad partnership is required between parental psychopathology (addressed by adult psychiatrists) and child protection and development (a mandate of youth mental health professionals) to hold the family unit for prolonged periods. Although the endorsement by the ICD11 of the Complex Post-Traumatic Stress Disorder is good news for clinicians working with refugees, ²¹ much more concerted clinical and research efforts are needed to develop appropriate care for these cases, in which language barriers often add a layer of complexity.

In the present issue, Kronick summarizes the recent evidence on the effectiveness of assessment and treatment for refugee adults and children. She emphasizes that, because of the importance of environmental factors in the post-migratory environment, systemic and family approaches should be privileged. She also stresses that cultural appropriateness of treatment should be a constant preoccupation for clinicians, and that existing evidence may not be automatically generalized to a wide range of diverse cultural groups.

Implications for Psychiatry Services and Psychiatrists

The refugee phenomenon is multifaceted and related to the rapidly evolving, large, social, political, and economic forces. Psychiatrists may feel overwhelmed in this context and minimize their roles in addressing the associated high levels of human suffering and mental health disorders. Although limited, there are significant ways in which mental health institutions and psychiatrists can make a difference for refugee mental health, beyond the clinician’s commitment to compassion and good quality:

Training: Resident training and continuing education can promote cultural competence training programs that address the present refugee predicament and deconstruct some of the prevailing prejudices about refugees to promote a more empathic understanding. ^22,23 The CPA training guidelines address these issues and propose pedagogical approaches that could be useful to help services address the present refugee influx. ²⁴

Model of services: A phased approach, which proposes to prioritize non-specific psychosocial interventions until some emotional and social safety is established, is more pertinent than ever. ¹⁰ Non-specific psychosocial interventions targeting the baseline safety, employment, education, and immigration status are at the forefront during resettlement. Although more evidence is needed, involving progressive community organizations and lay workers in the delivery of well-circumscribed (and sometimes virtual) trauma intervention may be a promising avenue. Because the risks of harm are not negligible, this cannot be done without close monitoring of both processes and outcomes. ²⁵

Advocacy: Through a public health model, in partnership with other actors in the social and medical fields, psychiatrists may influence decision makers by providing information about mental health determinants in the post-migratory environment and proposing protective social policies. ^26,27 Finally, we may also have to address the heterogeneity of positions within psychiatry to better define our role and mandate in refugee mental health and to address the delicate balance between the respect of individual positions and the ethical debates that are associated with this humanitarian crisis.