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.
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.
This is the first module of the oldest and longest running course in this field in the UK and aims to assist those working with asylum seeking...Find out more
The central focus of this course is to introduce a therapeutic dimension and a psychosocial perspective to working with refugees and asylum...Find out more
Provides culturally sensitive support to refugees and asylum-seeking children, young people and families in north London.