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Honduran migrant Elizabeth Umanzor hugs her six-year-old daughter Gina outside the tent where their family of five is sleeping at an sports complex sheltering more than 5,000 Central American migrants in Tijuana, Mexico, Nov. 28, 2018. (AP Photo/Rebecca Blackwell)

How to develop the mental health care that refugees really need

From the migrant caravan that has travelled across Central America, to the ongoing exodus from Syria, the plight of refugees has become a global crisis.

There are currently more refugees and asylum seekers fleeing conflict and violence around the world than ever before. The media lays out the trauma of this forced migration on our screens: Children who have witnessed parents assaulted or murdered; families forced to leave everything behind as they risk their lives on over-crowded, unseaworthy boats between Africa and Europe.

Most of these refugees end up stuck in camps for years, lacking basic necessities. Women and children face sexual or physical violence and human trafficking. The lucky ones make it to Canada — with a renewed sense of hope for a safer, better life.

When refugees arrive in Canada, they meet a health-care system that is often ill-equipped to address their complex social and psychological needs.

Our research team at Western University, which included clinical project staff Rita Van Meyel and Heather Harder, assessed the preparedness of mental health care services in London, Ont., to meet the needs of immigrants and refugees, including those experiencing trauma. We explored staff experiences as well as resources, supports and training for working across cultures and languages. We probed for relationships between the hospital and community agencies for examples of shared care.

Our findings, published in Public Health Reviews, are not reassuring. Health-care providers felt poorly prepared and supported to provide transcultural trauma-informed care.

Complex health challenges

The events forcing people to flee, and their difficult journeys across dangerous terrain and hostile borders, can have a devastating effect on mental health, according to our respondents working with refugees in mental health.

Rohingya refugee woman Jamila Begum holds her daughter Sameera in Unchiprang refugee camp near Cox’s Bazar, in Bangladesh, Nov. 16, 2018. (AP Photo/Dar Yasin)

The struggle to adjust and to establish a life in a new country can also be distressing, if not traumatizing. Many refugees face downward social mobility as their professional credentials and experience are not recognized. Intergenerational and gender conflicts emerge, as families are assailed with pressures to assimilate. Deep-seated trauma is often buried under burdens with more immediacy.

Refugees need comprehensive social and psychological supports to overcome trauma and begin a healing path. But the fragmentation of mental health services leaves patients experiencing little to no coordination of care.

Refugees experiencing trauma who present with multiple complex health challenges often end up retelling their trauma story to several different care providers. In one of our focus group sessions, social workers noted that the poor coordination and information sharing between care providers often meant that multiple people would each ask the same refugee patient to explain their trauma.

Universal problems of overcrowded spaces and long waitlists, hallmarks of “hallway medicine,” have repercussions throughout the health-care system.

Many staff in mental health that we interviewed felt overworked, that they could never catch up with the demands of their complex caseloads. Our study participants noted that they often do not have enough time to develop the trust needed for a therapeutic relationship with their clients, particularly in the initial assessments of clients experiencing trauma.

Trauma experiences are collective

Patient-centred care requires that patients can share their experience and expectations. Allowing them to tell their story and share their goals takes time. When care providers facilitate these personal narratives, it helps to identify what the real challenges are and to develop tailored solutions.

Members of a U.S.-bound migrant caravan cross the brother between the Mexican states of Chiapas and Oaxaca after Mexico’s federal police briefly blocked them outside the town of Arriaga, Oct. 27, 2018. (AP Photo/Rodrigo Abd)

A psychiatrist with training and expertise in transcultural mental health emphasized in a research interview that the identification of trauma and mental health itself is a culturally-biased process. How we express or understand mental health concerns varies across cultures and individuals.

A patient may take comfort in hearing the voice of their ancestor or muse, while the care provider calls it psychosis, and the family thinks they’re cursed. Building shared understandings take time.

Our health-care system is oriented to providing services for individuals. Many refugee families share a collective trauma experience. Their healing journey must also be a shared process. Care providers must consider the impact of trauma on the whole family. At the same time, they must analyse how each family member is coping through one-on-one time with a therapist.

Building interdisciplinary partnerships

Our research suggests that the current bottlenecks in the system could be resolved with effective task shifting and interdisciplinary models of team-based care. A social worker shared with us that when they collect and share the family narratives with the mental health team, psychiatrists can focus on treatment and recovery.

Staff told us they need time for training and access to resources around trauma-informed care. Care providers want skills for working in transcultural contexts, where services can integrate multiple cultural perspectives.

Although the Diagnostic and Statistical Manual (DSM5) now provides a guide for transcultural mental health assessments, care providers want a flexible approach and need sufficient time, allowing them to judge when patients are ready to share their stories.

Such a skill set would in fact be valuable for working with anyone needing mental health support. And let’s face it, most visits to the hospital are due to a scare that leaves all of us feeling vulnerable.

Building trauma-informed skills and supportive community partnerships will result in better mental health services for everyone — based on the compassion and caring that we all crave in our time of need.

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