We tried to examine the psychosocial strains and support for refugees in the area of conflict between psychology, politics and an intercultural scope.
Why should we care about this topic as a global health group?
War, torture, rape and death threats are global health risks, which can lead to long lasting consequences. Man-made disasters often leave deep tracks in body and soul and the suffering is not over when the actual threat ceases. Although the topic is in media focus at the moment, it has been existing for centuries.
Following the international classification system for Diseases (ICD-10), the two most prominent psychological strains regarding refugees are PTSD (post-traumatic stress disorder; F43.1) and Enduring personality change after catastrophic experience (F62.0).
Besides that, a lot of other strains often occur as a consequence of a catastrophic event, e.g. somatization disorder, depression, sleep and concentration disturbance, anxiety disorders and addiction. Post-migration stressors just shortly got recognition but are influencing mental health intensely (vi.).
The PTSD prevalence amongst victims of torture and war varies a lot. A study of Gaebel (2004) found that 40% of the asylum seekers and war refugees in Germany suffer from PTSD.
Generally speaking, 10-20% of victims of catastrophic events develop a PTSD. The durance (single vs. constant threat) and type of a traumatic event (accident vs. man-made disasters, e.g. torture or rape) are essential for developing a PTSD; 3-11% show PTSD symptoms after a single traffic accident and 50-55% after rape (Kessler et al., 1995; Perkonigg et al, 2000).
PTSD is the only psychological disorder characterised by an initiating event. The ICD-10 defines it as an “Exposure to a stressful event or situation (either short or long lasting) of exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone“ (Graubner, B; ICD-10-GM, 2014).
Suffering from the emotional impact of a traumatic event, even after some months have passed, is a normal reaction to an abnormal experience. If transient, the described afflictions are normal reactions to a shocking experience that would cause deep despair and intrusive, distressing memories in nearly every individual. Post-traumatic stress symptoms can also affect a previously healthy individual if unexpectedly exposed to an extremely distressing situation.
Post-migration stressors have a huge influence regarding coping and recovery from those situations.
Post-traumatic stress symptoms are:
A) Persistent remembering or “reliving” the stressor by intrusive flash backs, vivid memories, recurring dreams, or by experiencing distress when exposed to circumstances resembling or associated with the stressor.
B) Actual or preferred avoidance of circumstances resembling or associated with the stressor (not present before exposure to the stressor).
C) Either (1) or (2):
(1)Inability to recall, either partially or completely, some of the period of exposure to the stressor
(2) Persistent symptoms of increased psychological sensitivity and arousal exposure to the stressor) shown by any two of the following: staying asleep; anger; irritability or outbursts of difficulty in concentrating; hyper-vigilance; exaggerated startle difficulty in falling or response.
D) Criteria B, C (For some purposes, onset delayed more than six months may be included but this should be clearly specified separately.)
Traumatized people often have fragmented memories of the traumatic event and difficulties verbalising them. Incomplete memories as a symptom is often interpreted as non authentic in front of courts. For deciding if asylum is granted or not, courts demand a consistent story.
People who left their countries because of threat or dramatic events as well as people who experienced distressing moments during their escape and after the arrival have to cope with post-migration-stressors.
Post-migration stressors include aspects of the right of residence (durance of process, insecurity during the process), health and care (unemployment, group accommodations, poor psychosocial support) and family aspects as well as acculturation stress (changes in the roles within the family, loss of cultural frame, difficulties in communication). Acculturation stress describes the conflict of new learned behaviour/attitudes and originating values.
Coping with a traumatic event relies on the possibility to evolvement in the exile, the capacity to act as well as self-determination. The science of post-migration-stressors is in its infancy, but it shows its impact on mental health. There is a positive correlation between post-migration stressors and PTSD, depression and anxiety symptoms (Laban, Gernaat, Kamproe, van der Tweel & De Jong, 2005; Silove, Sinnerbrink, Field, Manicavasagar & Steel, 1997). The durance of the procedure for granting the right of asylum is a relevant risk factor for mental stress as well (Laban, Gernaat, Komproe, Schreuders & De Jong, 2004).
Heeren et al. (2014) show an association of differences in resident status and mental health outcomes. This results stress the importance of current socio-political living conditions for mental health.
Mueller, Schmidt, Steahell and Maier (2011) compared failed asylum seekers with pending and temporarily accepted asylum seekers and the high rates of psychopathology amongst failed asylum seekers indicate that refugee and humanitarian decision-making procedures may be failing to identify those most in need of protection.
Challenges in the field of psychology, politics and interculturality
Psychotherapy for refugees encouters special challenges as it is an interdisciplinary field of psychology, politics and interculturality.
There are systematic barriers. For example there is only access to medical care for acute disorders (§4 AsylbLG). Consequently, people getting treatment often have complex and chronic psychological symptoms.
Psychotherapy for refugees demands intercultural competence. The group of refugees is very heterogenic, so it is impossible to know everything about the client’s cultural background. Intercultural sensitivity demands to consideration of ones own values in terms of health and illness as one perspective and not as a universal concept. Dealing with ones stereotypes and prejudices is crucial. Clients might not be familiar with the concept of psychotherapy as an internal reflection process, so there can be misunderstandings and stress on the client’s and care giver’s side. As a result, psychotherapy should focus on an individual level and has to be flexible for a wide spectrum of interventions. Besides the treatment of symptoms, therapy has to consider influences on a political as well as a cultural level and post-migration stressors.
People who experienced man-made disasters often loose confidence their social surrounding. As a normal reaction they distrust people and withdraw themselves. Distrust makes a trustful client-therapist relationship – which is essential – difficult. This is a reason why a lot of people leave therapy.
Psychotherapists working in this field have to deal with more than the psychological inner world of the patient. The neutral position of a therapist is difficult and questionable when encountering health and human rights. Neutrality is of little use when it comes to man-made disasters such as torture or rape.
As psychotherapists have to write reports that influence the process of asylum, they encounter working dilemmas. They need a professional credibility, while at the same time it is difficult to be responsible for the decision of return. Who can decide if a return is possible for an individual as the feeling of threat is subjective even if there is no actual threat anymore?
The clinical and diagnostic instruments we use often misinterpret or overestimate symptoms. As an example in the SCL-90 the question 43 „do you have the feeling that people observe and talk about you“ is not a hint for a paranoid symptom – it is a fact that people of a different background are unfortunately often still considered „foreign“. So there is a need for new diagnostic instruments!
Another aspect is the language barrier, which is mainly overcome by using interpreters. Interpreters are a very important linguistic as well as cultural bridge. They have to manage the difficulties of translating literally while regarding cultural aspects. The Turkish saying „my liver is getting big“ is not an organic description, but a way to express dolefulness. Interpreters working in these areas encounter special challenges as well. It can be very difficult to translate emotional content and not exact influence on the results of the talk. Consequently, the therapist and interpreter have to cooperate intensively and maintain their professional roles.
There is a complex relationship between stressing factors before, during, and after the flight. This causes complex symptoms and demands a subjective approach and trauma therapy is just a little part of it. There is need for multi-modale and integrative methods for interdisciplinary care givers. Psychological consequences of e.g. accommodations or the procedure for granting the right of asylum should be considered in politics. Fragmented memory caused by traumas have to be recognized in front of courts. There are many other barriers such as access to mental health, resources like psychosocial workers with intercultural sensitivity. There is still a long way to go, but humanity and human rights require us to overcome these obstacles.
Author: Anna Kanitz