Mental Health and Migrant Populations
Find out more about our #MHForAll webinar series here.
Dinesh Bhugra, Professor of Mental Health and Cultural Diversity at the Institute of Psychiatry, Psychology and Neuroscience at King's College London.
Gulli Schinina, IOM
Monica Blotevogel, Coreszon
Juliet Cohen, Freedom from Torture
David Karorero, Youth Activist and Founder of Burundian Youth for a Brighter Future
There are several challenges we need to bear in mind. First of all there are around 281 million international migrants around the world, but also a lot of internal migration within countries, particularly between rural and urban areas. Each group brings with it a unique set of challenges, both for the new country and the country they leave behind. The Oxford Textbook of Migrant Psychiatry, kindly supported by IOM, explores this further.
Beginning with our first question for the panel, how do you see the challenges in migrant psychology?
The IOM operates in more than 80 countries worldwide serving 700,000 migrants around the world in the last year.
2021 is a year in which mental health should leave no one behind. This includes the vast and diverse migrant populations. This doesn’t just mean clinical support, but a multi-tiered whole system effort towards social justice and social support.
The past year has brought about psychosocial difficulties for most of us; isolation, uncertainty, lack of clarity about support, and the constant waiting for change. In a way these experiences should make the plight of migrants more relatable to us, but this does not mean in any way that the experience for migrants has been made any easier. Bleaker economic prospects, and the closing of borders, make it more difficult to go home. In some situations they are forcibly detained and repatriated. They are even more distanced from loved ones, and even more lacking of certainty and any understanding of the situation due to language barriers.
“Migrant” is a term that covers a huge group of people - people in camps, in transit, in detention, or recently arrived at their destination when COVID-19 hit. We should not fall into the trap of thinking that all migrants have the same experience. Even in most developed countries migrants do not enjoy the same access to mental health care. This can be for many reasons including a lack of information and cultural barriers to services as well as dependent on their legal status. .
In 2021 we all need access to mental health care, and migrants should not be stigmatised or considered more at risk because of their status.
How do you deal with migrants and refugee issues in Hamburg, particularly in relation to barriers to health care?
As Gulli said, there are many barriers; understanding of European healthcare systems, lack of access, and cultural sensitivity are all important factors.
Cultural values and attitudes are also important. The EU system is very individualistic. This makes it difficult to build trust between migrant and mental health workers. Proximity is also key. Coreszon focuses on community health care, aiming to remove barriers and train peer support workers to build community level support for migrant workers.
The more we’re able to spread knowledge and an understanding of how to access care, as well as care for each other, the easier it is for people to access care when they need it. Small moments in relationships are crucial to changing attitudes. The majority of our team have some kind of lived experience relevant in this area.
Some migrants have already had mental health problems before arriving in the host country - some have PTSD from the journey or from the warzone or country that they are leaving. Even those who haven't had previous mental health conditions can develop them due to lack of perspective or their treatment by the host country.
My project works to build up hope in migrant youth from Burundi, and prepare them for a brighter future. We do this to help them believe in themselves again, as we have a lot of broken dreams in these communities. In our project everything is done through preventive and immediate care. We try to put on some entertainment, and support with specialized education support programmes and other activities to keep them out of danger, as well as teaching them skills for their new country. We also connect them to professionals for any care needed.
What is your overview of all this from your work?
I was originally a GP, and now work more and more in forensic medicine, documenting evidence of torture. I see people who have experineced serious harm, such as victims of human trafficking, modern slavery etc.
At Freedom from Torture I help to train workers to use the Istanbul Protocol to identify victims, and we also work to gather evidence to support with asylum cases. The pressure of trying to get evidence for an asylum applicant to go to court means we have to push them to disclose very distressing experiences, which will be good evidence for their case, but also might not be something they want to share. Silence often feels easier than disclosure. Many have suffered sexual assault. We know that in the UK around 40% of victims of assault tell no one. Survivors of child sexual assault may take many years to tell anyone, or never tell anyone at all, despite it deeply affecting their quality of life.
We hope to help them not only get evidence for their case, but also to share what happened and consequently get access treatment they need - including specific specialized PSS therapies. It’s so important to be able to help people disclose these things, but it’s also so difficult.
There are challenges when arriving in a new country, and a question of what to disclose and how much, due to the risk of being stigmatized because of this. Do you perceive a difference between men and women in this area? And what should we be doing as clinicians to overcome that?
I find that gender differences are less evident than they used to be. 20 years ago it was not that common to have women talk about it, and rare to hear men talk about it. But it has become a more widely discussed topic across society, and the more it is covered in the media the less stigmatising it is.
More and more men are now able to disclose their experiences, and this perhaps upturns our understanding of what happens to these people. The belief that men were somehow able to resist this before, and that women were more often victims of assault, is now being put into question.
It is so important to look out for the clues for disclosure, and offer a gender choice when talking to healthcare professionals.
Do you find that men and women tend to respond differently in terms of responses to migration, and when seeking help for mental health?
Mental health for men is very difficult to work with; it is the elephant in the room. Categorisation and prioritisation of women and children in emergency responses is the first reason for this. According to protocols, women and children are automatically counted as vulnerable, whereas men are not.
No matter who the victim is, a man is most likely the perpetrator. oxic cultures of masculinity persist in many areas of the world, but men are not all perpetrators, and not all perpetrators are men.
Also men usually do not cry. They are rarely attracted to mental health services - they do not want to talk about their feelings even to a mental health professional. But this does not mean that they do not suffer. Men lose a lot in migration. But when they suffer their needs are often not met.
The situation is now very worrying as a result. Men are underrepresented in our MHPSS programmes - they are much less involved in support groups and they are not involved in activities. But they are overwhelmingly represented in psychiatric care.
We should do more in this field. As a psychological professional I have seen this problem many times, with victims of trafficking, of rape etc. When working with male victims it is always much more difficult to refer them to services, and often to see them as vulnerable. Also most mental health professionals are overwhelmingly female, and this has a significant impact.
There are two issues. At a practical level how do we help young families and children? And at a policy level, what do we do?
On a policy level, speeding up the asylum process and enabling families to access employment as fast as possible would have a significant impact. Reinstating the status that migrants have given up in their home country could prevent major problems in the long term. This has seen a lot of improvement in the last five years, but there is a long way to go.
At a community and social work level, more diversity among professionals is important. Mental health is a predominantly female profession, and more cultural diversity is needed, particularly among people who are caring for underserved populations. Training among professions, from family doctors to social workers, to sensitise people to possible barriers and how to address these, would also be beneficial.
More specifically I also think that the German insurance law needs to change to support peer to peer approaches more than it does. Right now if you are providing peer to peer intervention it will only be insured if you are qualified in psychology, social work or medicine. We are all crying out for more peer to peer and community based approaches, but this is not yet anchored in policy.
What would your advice be? How do we make sure that populations that migrate stay mentally healthy?
We are made victims by policies and not given a chance or equal treatment. We are labelled as migrants before we are labelled as human beings. We need international solidarity on this to ensure that our rights are observed. For example we need the right to health equity, the right to have mental health and psychosocial support, and also the right to education.
We need policy makers to give us the opportunity of being part of the solution, from designing, implementation and evaluation, because we are just being called as an afterthought. We are the solution, not the problem. We need to sit at the same table and fix the issues, together with policy makers, because we are in this together. No one is safe until we are all safe.
Question from the audience: A lot of clinical consultations are being done online. Migrants and refugees might be contacting people back home. What are the lessons we need to be aware of? One thing that strikes me is the mixed message, with the link between mental and physical health, for example. What should clinicians do?
It’s a big change and we have learnt a huge amount in the last year. At Freedom from Torture we had to switch from in person assessment to virtual, and pause the physical assement for scars. We decided to audit this change carefully as it was such a big shift, to see whether it was altering the quality of our medical reports, and to see how our processes were working for risk assessment.
Most of our asylum seekers in the UK were living alone in small rooms, in crowded accommodation, without any support around them. If they were triggered during the assessment, while talking about traumatic experiences from their past, who could they see for support? There was no one available to them, so we were very careful to risk assess every referral and decide whether it was appropriate to see them for a remote assessment.
When we are doing it in person we have the fluency of communication, picking up on body language etc., that you do not get remotely. I was very concerned about that, and about people’s ability to communicate what they wanted to say, in a setting where it is harder to build trust. But waiting for such a long time can also have an impact. So we’ve had to juggle this challenge, and it is an ongoing question for us.
This point about the matching of the therapist with the migrant is interesting. Do you feel we might end up medicalising normal human responses? For example if you’ve lost everything - your family, your belongings etc, how do we make sure we’re not pathologizing normal responses?
This is at the core of what we do. A lot of the stress we see is a completely normal, adequate response, so we try to focus on how to cope with this and share tools. We want to shift to normalising rather than pathologizing.
Our work is very much focussed on that. Pathologizing migrants is not supporting migrants. Psychological suffering is somehow an entry goal for the system, which is paradoxical. Many migrants, even in developed countries, do not have any access to mental health care. And when they do they require identification, which many will not want to provide. We need to mainstream mental health into primary care level.
What are your closing remarks?
The uncertainty that we are all going through now due to COVID-19 is important - we are constantly waiting for life to begin, or questioning if this is now normal life. That is the experience that we go through as migrants. I hope that this pandemic will make us better understand that feeling of uncertainty, and learn from the resilience of people that have already gone through this experience.
There is an urgent need for scaling MHPSS in IDP and camps. Mental health support is highly under-recognised in humanitarian settings. The financial and social implications are huge without support. Otherwise migrants risk developing mental health conditions.
We don't know what we don't know. We know that migrants and people of marginalised are susceptible to suicide, but the UK has very poor collection of national data on ethnicity and migration status of suicide cases. If all lives matter, why aren't we looking at this? Why don’t we know the ethnicity and migration status of suicides?
Working with the community is important. Not pathologizing normal reactions, but taking care of people with moderate or serious mental health disorders is important. This can be done with more mental health care at a primary level, and more legislation supporting this. Cultural awareness and understanding of these barriers should also be part of the formal training for professionals working with all migrants in this field.
I hope we can all come back and discuss this more. At a personal and policy level we need to tackle these issues very sensitively. The idea of cultural competence training is very important, and is good clinical practice.
The next two #MHForAll webinars will focus on child and youth mental health, and you can register your place here.