mental-health care for syrian refugees: clinical implications
TRANSCRIPT
Mental-Health Care for Syrian Refugees: Clinical Implications
Hussam Jefee-Bahloul, MD
Assistant Professor- University of Massachusetts Medical School
Lecturer- Yale School of Medicine
Hussam Jefee-Bahloul, MDUMASS Medical SchoolYale School of Medicine
Andres Barkil-Oteo, MD, MScYale School of Medicine
Outline
• Pre-settlement and post-settlement stressors
• Mental health disorders among conflict affected Syrians
• Barriers to accessing Mental Health (MH) care
• Adaptive coping
• Role of Psychotherapy and Medications
Pre-settlement
• Long journey of suffering and hardships
• Syrian refugees flee their homes due active war affecting their livelihood
• Some had to seek safety in areas:• Inside Syria
• Neighboring countries (Turkey, Jordan, Lebanon, or Iraq)
• Europe
• Other continents
• Exhausting transition in the temporary displacement countries
• Refugees utilize their dwindling resources.
• No access to proper education, jobs, adequate housing, or health services
• Disrupted social fabric loss of identity, estrangement, and overwhelming nostalgia to their country, Syria
• Discrimination against refugees and social tension (In some countries)
Settlement and beyond
• Unemployment• Acculturation • Lack of opportunities• Discrimination• Language inadequacy
• Newcomer refugees need 7-10 years to achieve economic stability (DeVortez et al 17)
• Poor finances less access to health care, education• Cultural identity and acculturation • Role of ethnic-like communities
Mental Health issues in Syrian refugees
• Conflict-affected Syrians may experience a range of mental disorders
1. Exacerbations of pre-existing mental disorders
2. Prompted by conflict-related violence and displacement
3. Related to adjustments in the post-emergency context
Loss and grief
Of…
• loved ones
• relationships
• meaning
• material objects
• ongoing exposure to news about the war
• constant fear about the safety or fate of family members
Violence and Torture
• Torture survivors may manifest symptoms of: depression, posttraumatic stress, panic, unexplained somatic symptoms and suicide.
• How helpful is the conventional diagnostic formulation in these patients?
• Shame and guilt: due to humiliating and degrading experiences of torture
• Shame and guilt: may prevent patients from seeking care.
Violence and Torture
It is advisable to:
• Avoid diagnostic labeling
• Work with each individual client case-by-case
• Use an integrated multidisciplinary team
• Support patients to cope with symptoms
• Focus on improving functionality: physical, psychological and social
Emotional Disorders
• Depression, complicated grief, posttraumatic stress symptoms are common
• Some of these symptoms may affect the individual’s ability to function
• Mostly mild-moderate
• Presence of symptoms does not necessarily indicate the presence of mental illness. (Almoshmosh 2015)
Emotional Distress: Clinical/“Sub-Clinical”
• Demoralization
• Hopelessness
• Due to profound and persistent existential concerns of safety, and trust in self, others, and surrounding
• Risk of Over-diagnosing
• Usefulness of Non-clinical interventions
Psychosis and other severe mental disorders
• Little data on current prevalence
• Excruciating stressors related to war and displacement
• Breakdown of social support networks
• Some psychotic symptoms can be culturally congruent
• Largest psychiatric hospital in Lebanon witnessed increase in severe psychopathology and suicidality of Syrians in the last few years compared (Lama, 2015)
Increase Risk
Alcohol and Substance use
• Heavy Smoking in Syrian males
• Consumption of alcohol in Syria has been traditionally low
• Use of alcohol may have increased after a war (Berns, 2014)
• Figures of use of illegal drugs are not available but may have increased given the increased production and trade of illegal drugs as a result of the crisis
• A worrying trend is the use of synthetic stimulants used such as fenethylline (‘Captagon’)
• In post-settlement settings access to alcohol (and possibly other drugs) may be easier
Barriers to accessing MH careLanguage • A major barrier to adequate care • Avoid using scientific language and jargon
• Collaboration with colleagues who share the background and language with the refugees
• Well-trained culturally competent mental health interpreters
Stigma • Emotional suffering is perceived as an inherent aspect of life
• Explicit labelling of distress as ‘psychological’ or ‘psychiatric’ may lead to shame and embarrassment
• Avoid using psychological jargon and psychiatric labelling
• Integrating mental health services into other care settings
Gender Differences • Women: (with their children) are more likely than before to seek mental health services
• Men: cultural pride and honorand change of social role can hinder access to care
• F: services are presented with more neutral terms such as “counselling”, and integrated within a “women’s program”
• M: providing information through regular integration processes (like social security, housing authorities, employment aid, etc.)
Mental health Interventions
• Fostering coping skills
• Treatment by psychotherapy• Psychoeducation
• Post-traumatic growth
• Cultural empowerment
• Indigenous healing
• Treatment by medications
Coping skills
• Refugees usually resort to maladaptive coping strategies such as smoking, obsessively watching the news and worrying about the ones still in Syria, withdrawal, or ‘doing nothing’.
• Reinforced by a perceived “loss of control” over life circumstances.
• Mental health providers must work with the refugee on:• Identifying each individual’s unique coping skills• Re-establishing positive and resilient pre-settlement coping strategies.
• Syrian women: • Adaptive coping: Praying and talking to family and friends. Using social networks. Organizing
charity and support groups, and bazars. Distraction.• Maladaptive coping: Over-sleeping, crying, smoking cigarettes, and isolating.
• Syrian men:• Adaptive coping: Working, visiting family and friends, playing sports, walking, and going out• Maladaptive coping: Over-sleeping, smoking cigarettes, and “getting angry”.
Psychotherapy
• Create a safe environment
• “The therapist is always going to be there for you”.
• Allow refugees to tell their story on their own pace.
• Be mindful that (avoidance) is a common defense mechanisms in cases of trauma
• Focus the work on present-day post-settlement stressors
• Encourage the use of available community support
Psychotherapy
• Psychotherapeutic boundaries: Refugees from the Arabic world may inquire about their therapists' backgrounds
• They can get confused if the therapists decline to share personal info
• Refugees may expect the therapists to express their emotional reactions in session.
• Therapists to consider “flexibility” in navigating the boundaries as “neutrality” may hinder efforts to establish rapport with refugees.
• Syrians are reluctant to engage in “group psychotherapy” especially if the theme of sessions is focused on “therapy” and “process”. Vs. “socializing” session or “psychoeducational” groups
Psychoeducation
• Educating refugees about normal and complicated response to trauma,
• Available resources for physical and mental health
• Somatic symptoms may be at the frontline of mental health presentations of refugees.
• Educating refugees about the somatic component of their reaction to trauma might help to relieve the confusion as why he/she are referred to a mental health provider.
Post-Traumatic Growth-Focused psychotherapies • Cognitive Behavioral Therapy (CBT), Cognitive Processing Therapy
(CPT), Eye Movement desensitization and reprocessing (EMDR), or Exposure Narrative Therapy (ENT), etc.• Mollica (1988) points to the potential of “re-traumatizing” refugees
• Very few studies conducted on Syrian refugees’ • In Turkey a study using EMDR in Syrian refugees is showing promising results.
(Acarturk, 2015)
• (Mindfulness) may present a valid modality in Syrian culture. • Self-transformation and human potential, will power, values of education and
self-monitoring, and practices of prayer, meditation, and other behavioral modifications.
Cultural empowerment
• Build social “mastery” within refugees
• Strengthening family ties and social networking • Involve family members in mental health care sessions
• Syrian culture praises family ties: individualistic approach might not fit
• Including family when making treatment plans involving the whole family in the healing process
• Providers as “social advocates” help the refugee and the family to gain more social ground (navigate social resources for financial, vocational, language-learning, and housing services)
Indigenous healing
• Retention of cultural identity while incorporating elements of the new culture helps the healing
• Involvement of cultural brokers such as community leader (Arabic community) or religious leaders (Imams or Syrian Christian priests)
• Individual OR Community programs
• Goal to “restore” relationships and build new “healthy” patterns of interaction, communication, and coping.
• Creativity-based group programs using the arts (such as theater, signing, drawing, knitting, writing poetry
Medications• Psychotropic medications are usually effective among refugees• No large scale effectiveness studies in resettled refugees• Non-compliance is common psychoeducation • High co-morbidity • Thorough assessment before considering meds • Consider refugee preference and expectations: stigma, • Inter-individual and cross-ethnic response profile to psychotropics• Genetic and/or environmental (epigenetic) factors• High frequencies of alleles on the gene CYP2D6 that is associated with
being ultra-rapid metabolizer (affects Tricyclic Antidepressants and SSRIs, • Pharmacogenomics is “dynamic” the change of environmental
conditions does affect the expression of genes.
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