Refugee Week – The complex mental health needs of refugees

23 June 2017

By Dr David Bell

In this week when we are all thinking about refugees, this excellent video from Médecins sans Frontières is a very timely reminder of the suffering that so many refugees endure. In my own work as a psychiatric expert, I have interviewed many hundreds of people who have suffered in the ways outlined in the film. I think, however, that we currently lack the appropriate diagnostic categories to capture the difficulties they face.

Image of refugees from Doctors Without Borders

Although many refugees suffer from the typical symptoms of Post Traumatic Stress Disorder (such as flashbacks, intrusive thoughts, hallucinations, claustrophobic panic, nightmares, depersonalisation, social isolation) in my view this is not an appropriate diagnosis. It does not adequately cover the complexity of their situation. The diagnosis of PTSD is more appropriate to those who have suffered one or a few discrete traumatic events which have a clear temporal and causal relationship to the symptomatic picture. However, in most refugee cases, there has been a long history of cumulative trauma – for example years of living under threat, witnessing of extreme violence, bereavements. This is then followed by the traumatic separation caused by leaving their homeland and family – whose existence may itself be very precarious and so a constant source of persecuting preoccupation. They start their journeys – often months or even more than a year travelling in situations where they are not cared for – in an already highly vulnerable state. We also need to bear in mind that these individuals are often minors. They then arrive in a foreign country they do not understand, cut off from any contact with their families. In some cases, there is no proper provision for them on arrival, and many are subject to detention.

I argue that in these situations a more appropriate diagnosis is ‘Chronic Traumatised State’. Such individuals are often suffering from the typical symptoms of severe depression (suicidal ideation, a profound feeling of nihilism, and deep feelings of irrational guilt as part of ‘survivor syndrome’). However, there is no firm dividing line between Severe Depressive Disorder and Chronic Traumatised State, many symptoms being common to both. Further, traumatised states when they become chronic often eventuate in Severe Depressive Disorder. Lastly, this long period of cumulative trauma can result in changes in personality structure which will require many years of rehabilitation and specialist psychological help.

These individuals therefore require proper psychological assessment and support from specialist professionals. Fundamental here is the provision of secure, enduring and trusting relationships with mental health personnel. Medication has very little role to play given the complexity and chronicity of these disorders.

I commend every effort made this week to highlight the plight of refugees and draw attention to their mental health needs. I hope this is something which continues to see more thoughtful consideration.

Dr David Bell is a past president of the British Psychoanalytic Society. He is a consultant psychiatrist in the Adult Department of the Tavistock and Portman where he directs a specialist unit for serious/enduring complex disorders. He is one of the U.Ks leading psychiatric experts in asylum and human rights and heads up the Tavistock Immigration Legal Service.

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