mental-health care for syrian refugees: clinical implications
TRANSCRIPT
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Mental-Health Care for Syrian Refugees: Clinical Implications
Hussam Jefee-Bahloul, MD
Assistant Professor- University of Massachusetts Medical School
Lecturer- Yale School of Medicine
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Hussam Jefee-Bahloul, MDUMASS Medical SchoolYale School of Medicine
Andres Barkil-Oteo, MD, MScYale School of Medicine
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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
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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
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• 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)
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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
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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
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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
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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.
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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
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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)
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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
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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
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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
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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.)
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Mental health Interventions
• Fostering coping skills
• Treatment by psychotherapy• Psychoeducation
• Post-traumatic growth
• Cultural empowerment
• Indigenous healing
• Treatment by medications
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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”.
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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
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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
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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.
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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.
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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)
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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
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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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Plug ins…